Internet Claim (iClaim) Application

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

OMB: 0938-0251

IC ID: 245773

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Internet Claim (iClaim) Application
 
No Modified
 
Voluntary
 
42 CFR 406.7, 42 CFR 406.10 42 CFR 406.11 42 CFR 406.20 42 CFR 406.6, ,

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

Health Health Care Services

 

878,553 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 878,553 0 0 0 0 878,553
Annual IC Time Burden (Hours) 219,638 0 0 0 0 219,638
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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