Application for Enrollment in Medicare Part B (Medical Insurance)

Application for Enrollment in Medicare - The Medical Insurance Program (CMS-40B)

Documents and Forms

Document Name Document Type
Form CMS-40B (SP) Application for Enrollment in Medicare Part B (Medical Insurance) Form and Instruction
CMS-40B (SP) Solicitud De Inscripci?n Para Medicare Parte B (Seguro M CMS40B-S.pdf www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf Form and Instruction
CMS-40B (SP) Solicitud De Inscripcion En La Parte De Medicare (Seguro Spanish_CMS-40B_508_Enabled revised.pdf www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf Form and Instruction
CMS-40B Application for Enrollment in Medicare Part B (Medical I CMS-40B_508_Enabled.pdf Form and Instruction
CMS-40B Application for Enrollment in Medicare Part B (Medical I CMS-40B_508_01.09.24.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Application for Enrollment in Medicare Part B (Medical Insurance)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-40B (SP)	Solicitud De Inscripcion En La Parte De Medicare (Seguro Medico)	Spanish_CMS-40B_508_Enabled revised.pdf	https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-40B	Application for Enrollment in Medicare Part B (Medical Insurance)	CMS-40B_508_01.09.24.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,068,715	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,068,715	668,715	400,000
Annual IC Time Burden (Hours)	265,288	165,288	100,000
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.