Information Collection

Application for Enrollment in Medicare Part B (Medical Insurance)

IC 209928 under ICR 202012-0938-016 · OMB 0938-1230.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1230 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-40B Application for Enrollment in Medicare Part B (Medical Insurance)	Form and Instruction
CMS-40B (SP) Solicitud De Inscripci?n Para Medicare Parte B (Seguro M CMS40B-S.pdf www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf	Form and Instruction
CMS-40B Application for Enrollment in Medicare Part B (Medical I CMS 40-B 508.pdf	Form and Instruction

IC Title:

Application for Enrollment in Medicare Part B (Medical Insurance)

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-40B (SP)	Solicitud De Inscripci?n Para Medicare Parte B (Seguro M?dico)	CMS40B-S.pdf	https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-40B	Application for Enrollment in Medicare Part B (Medical Insurance)	CMS 40-B 508.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	400,000	400,000
Annual IC Time Burden (Hours)	100,000	100,000
Annual IC Cost Burden (Dollars)	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.