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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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:

table that charts list of 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

Federal Enterprise Architecture Business Reference Module

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 %

table that charts list of burden
	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

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.