Application for Hospital Insurance

Application for Hospital Insurance (CMS-18F5)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0251 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-18F5 Application for Hospital Insurance Form
CMS-18F5 CMS-18F5.Application for Hospital Insurance (7-27-18) CMS-18F5.Application for Hospital Insurance (7-27-18).pdf Form
CMS-18F5(SP) CMS-18F5_SP. Solicitud Para El Seguro De Hospital CMS-18F5_SP. Solicitud Para El Seguro De Hospital(7-27-18).pdf Form

Information Collection (IC) Details

IC Title:	Application for Hospital Insurance	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 406.20 42 CFR 406.7 42 CFR 406.6 42 CFR 406.11 42 CFR 406.10

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-18F5	CMS-18F5.Application for Hospital Insurance (7-27-18)	CMS-18F5.Application for Hospital Insurance (7-27-18).pdf		Yes	No	Fillable Printable
Form	CMS-18F5(SP)	CMS-18F5_SP. Solicitud Para El Seguro De Hospital	CMS-18F5_SP. Solicitud Para El Seguro De Hospital(7-27-18).pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 51,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	51,000	1,000	50,000
Annual IC Time Burden (Hours)	29,580	17,080	12,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.