Individual Application

Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and CHIP Agencies (CMS-10440)

Documents and Forms

Document Name Document Type
Att A.-App3 PRA Electronic Application Final.xlsx Instruction
Att A.-App3 PRA Electronic Application Final.xlsx Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs (Sho Att B.-Individual-application-with-costs-help-short-form-508.pdf Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs (Sho Att B.-Individual-application-with-costs-help-short-form-508.pdf Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs Att C.-Application-with-costs-help-508.pdf Form and Instruction
CMS-10440 Application for Health Coverage & Help Paying Costs Att C.-Application-with-costs-help-508.pdf Form and Instruction
CMS-10440 Application for Health Coverage (no cost help) Att D.-Application-no-cost-help.pdf Form and Instruction
CMS-10440 Application for Health Coverage (no cost help) Att D.-Application-no-cost-help.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Individual Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR Parts 431, 435, 457 26 CFR 1 and 602 45 CFR Parts 155, 156, 157 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Att A.-App3 PRA Electronic Application Final.xlsx	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Application for Health Coverage & Help Paying Costs (Short Form)	Att B.-Individual-application-with-costs-help-short-form-508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Application for Health Coverage & Help Paying Costs	Att C.-Application-with-costs-help-508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Application for Health Coverage (no cost help)	Att D.-Application-no-cost-help.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,084,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,084,000	200,000	4,884,000
Annual IC Time Burden (Hours)	2,402,714	197,100	2,205,614
Annual IC Cost Burden (Dollars)	0	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.