Application for Enrollment in Medicare - The Medical Insurance Program (CMS-40B)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-40B (SP) Application for Enrollment in Medicare Part B (Medical Insurance)	Form and Instruction	Modified	Available
CMS-40B (0938-1230).Justification of Non-substantive Change.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2018-04-16	Available
CMS-40B - Supporting Statement A - Passback CMS Responses 1-29-18 rev 01-30-2018 by OSORA PRA - CLEAN.doc	Supporting Statement A	Uploaded 2018-02-13	Available
Crosswalk Changes OMB 0938-1230 CMS-40B.XLSX	Supplementary Document	Uploaded 2018-01-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
209928	Application for Enrollment in Medicare Part B (Medical Insurance)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1230	ICR Reference No: 201804-0938-005
Status: Active	Previous ICR Reference No: 201707-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Application for Enrollment in Medicare - The Medical Insurance Program (CMS-40B)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/14/2018
	Date Received in OIRA: 04/16/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2021	02/28/2021	02/28/2021
Responses	400,000	0	400,000
Time Burden (Hours)	100,000	0	100,000
Cost Burden (Dollars)	0	0	0

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Abstract: The Form CMS-40B is used to establish enrollment in Supplementary Medical Insurance (Part B). The information collected on the form is needed to determine an individual's eligibility for Medicare Part B.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1836 Name of Statute: null
   Statute at Large: 18 Stat. 1840 Name of Statute: null
  

Citations for New Statutory Requirements: Statute at Large: 18 Stat. 1840 Name of Statute: null
Statute at Large: 18 Stat. 1836 Name of Statute: null

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 14517	03/21/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 31609	07/07/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Application for Enrollment in Medicare Part B (Medical Insurance)	CMS-40B, CMS-40B (SP)	Solicitud De Inscripci?n Para Medicare Parte B (Seguro M?dico) ,   Application for Enrollment in Medicare Part B (Medical Insurance)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	400,000	400,000	0	0	0	0
Annual Time Burden (Hours)	100,000	100,000	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $972,554

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/16/2018

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