Information Collection Request
Request for Enrollment in Supplementary Medical Insurance (SMI) and Supporting Regulations in 42 CFR 407.10, 407.11 and 408.40(a)(2) (CMS-4040)
ICR 202305-0938-014 · OMB 0938-0245 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-0245 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CMS-4040 Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 |
Form and Instruction | Modified | Repair queued |
 CMS 4040 Supporiting Statement A.docx |
Supporting Statement A | Uploaded 2023-05-31 | Repair queued |
 Justification - Use of SSNs 0938-0245 CMS-4040.pdf |
Supplementary Document | Uploaded 2017-02-17 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 7901 |  Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-0245 |
| Type of Information Collection | Extension without change of a currently approved collection |
| Previous ICR Reference No | 202003-0938-015 |
| Agency Tracking No | CM-CPC |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |