Information Collection

Application for Hospital Insurance

IC 7908 under ICR 201804-0938-022 · OMB 0938-0251.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-18F5 CMS-18F5.Application for Hospital Insurance (7-27-18) Application for Hospital Insurance	Form
Form CMS-18F5(SP) CMS-18F5_SP. Solicitud Para El Seguro De Hospital 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

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-18F5				Yes	No	Fillable Printable
Form	CMS-18F5(SP)				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 %

table that charts list of burden
	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

table that charts IC Documents
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.

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