Information Collection

Individual Application

IC 205692 under ICR 201903-0938-016 · OMB 0938-1191.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1191 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10440 Individual Application Form and Instruction
CMS-10440 CMS-10440 - Attachment A-Individual Online Application Q CMS-10440 - Attachment A Electronic Questionnaire.pdf Form and Instruction
CMS-10440 Attachment C - Paper Application - FA Family, plus appen CMS-10440 Attachment C - Application for Health Coverage.pdf Form and Instruction
CMS-10440 Paper Application - non-FA, plus appendices CMS-10440 Attachment D - Application for Health Coverage.pdf Form and Instruction
CMS-10440 Electronic Questionnaire Additional Items CMS-10440 Attachment A1 Electronic Questionnaire Additional Items.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Individual Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR Parts 155, 156, 157 42 CFR Parts 431, 435, 457 26 CFR 1 and 602 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10440	CMS-10440 - Attachment A-Individual Online Application Questionnaire	CMS-10440 - Attachment A Electronic Questionnaire.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Attachment C - Paper Application - FA Family, plus appendices	CMS-10440 Attachment C - Application for Health Coverage.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Paper Application - non-FA, plus appendices	CMS-10440 Attachment D - Application for Health Coverage.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Electronic Questionnaire Additional Items	CMS-10440 Attachment A1 Electronic Questionnaire Additional Items.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4,195,800	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,195,800	-599,400	4,795,200
Annual IC Time Burden (Hours)	713,286	-101,898	815,184
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.