Information Collection

Individual Application

IC 205692 under ICR 202405-0938-008 · OMB 0938-1191.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1191 can be found here:

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

Information Collection (IC) Details

View Information Collection (IC)

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: 26 CFR 1 and 602 45 CFR Parts 155, 156, 157 42 CFR Parts 431, 435, 457 (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
Form and Instruction	CMS-10440	Application for Health Coverage & Help Paying Costs (Short Form)	CMS-10440 - 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	CMS-10440 - Att C.-Application-with-costs-help-508.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	Application for Health Coverage (no cost help)	CMS-10440 - Att D.-Application-no-cost-help.pdf	Yes	Yes	Fillable Fileable
Form	CMS-10440	Electronic application.	CMS-10440 - Att A.-Electronic Application Final.xlsx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,031,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,031,000	147,000	4,884,000
Annual IC Time Burden (Hours)	2,345,999	140,385	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.