Application for Part A (Hospital Insurance)

Application for Enrollment in Medicare Part A, Internet Claim (iClaim) Application Screen, Modernized Claims System and Consolidated Claim (CMS-18F5)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0251 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-18F5 Application for Part A (Hospital Insurance) Form
CMS-18F5 Application for Part A (Hospital Insurance) CMS-18-F-5.pdf Form
CMS-18F5 Application for Part A (Hospital Insurance) CMS-18-F-5.pdf Form

Information Collection (IC) Details

IC Title:	Application for Part A (Hospital 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: 42 CFR 406.6 42 CFR 406.11 42 CFR 406.7 42 CFR 406.10 42 CFR 406.20

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-18F5	Application for Part A (Hospital Insurance)	CMS-18-F-5.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 696	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	696	-50,304	51,000
Annual IC Time Burden (Hours)	174	-29,406	29,580
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.