Application for Enrollment in Medicare - The Medical Insurance Program (CMS-40B)

ICR 202012-0938-016

OMB: 0938-1230

Federal Form Document

Forms and Documents
Document
Name
Status
Form and Instruction
Modified
Supporting Statement A
2020-12-23
IC Document Collections
ICR Details
0938-1230 202012-0938-016
Received in OIRA 201804-0938-005
HHS/CMS CM-CPC
Application for Enrollment in Medicare - The Medical Insurance Program (CMS-40B)
Extension without change of a currently approved collection   No
Regular 12/29/2020
  Requested Previously Approved
36 Months From Approved 02/28/2021
400,000 400,000
100,000 100,000
0 0

The Form CMS-40B is used to establish enrollment in Supplementary Medical Insurance (Part B). The information collected on the form is needed to determine an individual's eligibility for Medicare Part B.

Statute at Large: 18 Stat. 1836 Name of Statute: null
   Statute at Large: 18 Stat. 1840 Name of Statute: null
  
None

Not associated with rulemaking

  85 FR 60170 09/24/2020
85 FR 83966 12/23/2020
No

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 400,000 400,000 0 0 0 0
Annual Time Burden (Hours) 100,000 100,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$1,026,934
No
    Yes
    Yes
No
No
No
No
Stephan McKenzie 410 786-1943 [email protected]

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
12/29/2020


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