Information Collection

Individual Application

IC 205692 under ICR 202208-0938-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Att A.-App3 PRA Electronic Application Final.xlsx	Instruction
Att A.-App3 PRA Electronic Application Final.xlsx	Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs (Sho Att B.-Individual-application-with-costs-help-short-form-508.pdf	Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs (Sho Att B.-Individual-application-with-costs-help-short-form-508.pdf	Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs Att C.-Application-with-costs-help-508.pdf	Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs Att C.-Application-with-costs-help-508.pdf	Form and Instruction
CMS-10440 Application for Health Coverage (no cost help) Att D.-Application-no-cost-help.pdf	Form and Instruction
CMS-10440 Application for Health Coverage (no cost help) Att D.-Application-no-cost-help.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Individual Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR Parts 155, 156, 157 42 CFR Parts 431, 435, 457 26 CFR 1 and 602 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Att A.-App3 PRA Electronic Application Final.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Application for Health Coverage & Help Paying Costs (Short Form)	Att B.-Individual-application-with-costs-help-short-form-508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Application for Health Coverage & Help Paying Costs	Att C.-Application-with-costs-help-508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Application for Health Coverage (no cost help)	Att D.-Application-no-cost-help.pdf	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,884,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	4,884,000	688,200	4,195,800
Annual IC Time Burden (Hours)	2,205,614	1,492,328	713,286
Annual IC Cost Burden (Dollars)	0	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.