Information Collection

Application for Health Coverage and Help Paying Costs Short Form

IC 206713 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⚠️ Notice: This information collection may be referencing outdated material.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 Application for Health Coverage and Help Paying Costs Short Form Form and Instruction
CMS-10440 CMS-10440 - Attachment B - Application for Health Covera CMS-10440 Attachment B - Application for Health Coverage and Help Paying Costs.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Health Coverage and Help Paying Costs Short Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10440	CMS-10440 - Attachment B - Application for Health Coverage & Help Paying Costs (Short Form)	CMS-10440 Attachment B - Application for Health Coverage and Help Paying Costs.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 466,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	466,200	-66,600	532,800
Annual IC Time Burden (Hours)	233,100	-33,300	266,400
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.