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

ICR 202304-0938-004

OMB: 0938-0251

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-18F5 Application for Part A (Hospital Insurance) Form	Modified
Form CMS-18F5 Application for Part A (Hospital Insurance) Form	Modified
Form CMS-18F5 Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE)) Form and Instruction	Unchanged
Form CMS-18F5 Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE)) Form and Instruction	Unchanged
Form CMS-18F5 Internet Claim (iClaim) Application Form and Instruction	Modified
Form CMS-18F5 Internet Claim (iClaim) Application Form and Instruction	Modified
Non-sub Change Request Memo CMS 18F5.docx Justification for No Material/Nonsubstantive Change	2023-04-10
Non-sub Change Request Memo CMS 18F5.docx Justification for No Material/Nonsubstantive Change	2023-04-10
Crosswalk of Changes CMS 18F5 OMB 0938 0251.docx Supplementary Document	2023-04-10
Crosswalk of Changes CMS 18F5 OMB 0938 0251.docx Supplementary Document	2023-04-10
CMS-18F5 - Supporting Statement A - Clean.docx Supporting Statement A	2021-05-25
CMS-18F5 - Supporting Statement A - Clean.docx Supporting Statement A	2021-05-25
Justification for Collecting Social Security Numbers.pdf Supplementary Document	2021-02-12
Justification for Collecting Social Security Numbers.pdf Supplementary Document	2021-02-12

IC Document Collections

IC ID	Document Title	Status
7908	Application for Part A (Hospital Insurance) Form	Modified
7908	Application for Part A (Hospital Insurance) Form	Modified
245774	Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE)) Form and Instruction	Unchanged
245774	Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE)) Form and Instruction	Unchanged
245773	Internet Claim (iClaim) Application Form and Instruction	Modified
245773	Internet Claim (iClaim) Application Form and Instruction	Modified