Internet Claim (iClaim) Application

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⚠️ Notice: This information collection may be referencing outdated material.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 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

Information Collection (IC) Details

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:

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 %

	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

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.