Internet Claim (iClaim) Application

Application for Enrollment in Medicare Part A, Internet Claim (iClaim) Application Screen, Modernized Claims System and Consolidated Claim (CMS-18F5)

Documents and Forms

Document Name Document Type
Form CMS-18F5 Internet Claim (iClaim) Application Form and Instruction
CMS-18F5 iClaim SEP Screens Proposed iClaim SEP Screens 10052022.docx Form and Instruction
CMS-18F5 CAA - SEP UI Mock-ups Proposed CAA - SEP UI Mock-ups -.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Internet Claim (iClaim) Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 406.10 42 CFR 406.11 42 CFR 406.20 42 CFR 406.6, , 42 CFR 406.7,

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-18F5	iClaim SEP Screens	Proposed iClaim SEP Screens 10052022.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-18F5	CAA - SEP UI Mock-ups	Proposed CAA - SEP UI Mock-ups -.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,134,262	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,134,262	255,709	878,553
Annual IC Time Burden (Hours)	283,565	63,927	219,638
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.