Information Collection

Internet Claim (iClaim) Application

IC 245773 under ICR 202304-0938-004 · OMB 0938-0251.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-18F5 Internet Claim (iClaim) Application	Form and Instruction
Form CMS-18F5 Internet Claim (iClaim) Application	Form and Instruction
CMS-18F5 iClaim SEP Screens Proposed iClaim SEP Screens 10052022.docx	Form and Instruction
CMS-18F5 iClaim SEP Screens Proposed iClaim SEP Screens 10052022.docx	Form and Instruction
CMS-18F5 CAA - SEP UI Mock-ups Proposed CAA - SEP UI Mock-ups -.docx	Form and Instruction
CMS-18F5 CAA - SEP UI Mock-ups Proposed CAA - SEP UI Mock-ups -.docx	Form and Instruction

IC Title:

Internet Claim (iClaim) Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 406.7, 42 CFR 406.10 42 CFR 406.11 42 CFR 406.20 42 CFR 406.6, ,

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-18F5	iClaim SEP Screens	Proposed iClaim SEP Screens 10052022.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-18F5	CAA - SEP UI Mock-ups	Proposed CAA - SEP UI Mock-ups -.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 878,553

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	878,553	878,553
Annual IC Time Burden (Hours)	219,638	219,638
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.