Application for Part A (Hospital Insurance)

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

OMB: 0938-0251

IC ID: 7908

Information Collection (IC) Details

View Information Collection (IC)

Application for Part A (Hospital Insurance)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 406.7 42 CFR 406.10 42 CFR 406.20 42 CFR 406.6 42 CFR 406.11

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-18F5 Application for Part A (Hospital Insurance) CMS-18-F-5-508C.docx Yes No Fillable Printable
Form and Instruction CMS-18F5 Application for Part A (Hospital Insurance)_Spanish CMS-18-F-5 (508)enabled Spanish.docx Yes No Fillable Printable

Health Health Care Services

 

7,499 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 7,499 0 0 6,803 696 0
Annual IC Time Burden (Hours) 1,875 0 0 1,701 174 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

© 2024 OMB.report | Privacy Policy