Crosswalk

Revisions to Form CMS 18F5 (OMB 0938-0251) Application for Medicare Part A (Hospital Insurance)
The form was updated to add the optional collection of email addresses. The form was also updated to clarify the request for the
applicant’s name as it appears on their birth certificate. This change was based on public comment. No additional changes were made
and the burden was not impacted by the changes.
Changes

Updated Form
1c. Your Name as it
appears on your birth
certificate if different
than 1b.
1j. Email Address

Original Form
1c. Name at birth if it is
different than item 1b.

Reason for Change
Change in response to public
comment.

N/A

Form updated to give the
beneficiary an additional method
of communication. This field is
optional.