Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40

Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 (CMS-4040)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0245 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-4040 Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 Form and Instruction
CMS-4040 Request for Enrollment in Supplementary Medical Insuranc CMS 40-B 508.pdf Form and Instruction
CMS-4040 SP Solicitud De Inscripcion Para Medicare Part B (Seguro Me CMS-40B_SP_508.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40	Agency IC Tracking Number:	CM-CPC

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 407.10 42 CFR 408.40 42 CFR 407.11

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-4040	Request for Enrollment in Supplementary Medical Insurance	CMS 40-B 508.pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-4040 SP	Solicitud De Inscripcion Para Medicare Part B (Seguro Medico)	CMS-40B_SP_508.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 29,663	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	Previously Approved
Annual Number of Responses for this IC	29,663	-17,537	47,200
Annual IC Time Burden (Hours)	7,416	-4,384	11,800
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.