Information Collection

Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13

IC 7835 under ICR 202407-0938-001 · OMB 0938-0080.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-43 Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13	Form
CMS-43 Application for Hospital Insurance Benefits for Individu Redesigned CMS-43_508.pdf	Form
CMS-43 Application for Hospital Insurance Benefits for Individu Redesigned CMS-43_508.pdf	Form

Information Collection (IC) Details

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IC Title:

Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13

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 406.13 42 CFR 406.7

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-43	Application for Hospital Insurance Benefits for Individuals with End Stage Renal Disease	Redesigned CMS-43_508.pdf		No		Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 45,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	45,200	24,818	20,382
Annual IC Time Burden (Hours)	18,984	10,424	8,560
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.