Application for Part A (Hospital Insurance)

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: 7908

Information Collection (IC) Details

View Information Collection (IC)

Application for Part A (Hospital Insurance)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 406.7 42 CFR 406.10 42 CFR 406.20 42 CFR 406.6 42 CFR 406.11

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-18F5 Application for Part A (Hospital Insurance) CMS 18_F_5-Final.pdf Yes No Fillable Printable

Health Health Care Services

 

696 0
   
Individuals or Households
 
   0 %

  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 696 0 0 0 0 696
Annual IC Time Burden (Hours) 174 0 0 0 0 174
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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