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)

Documents and Forms

Document Name Document Type
Form CMS-18F5 Application for Part A (Hospital Insurance) Form and Instruction
CMS-18F5 Application for Part A (Hospital Insurance) CMS-18-F-5-508C.docx Form and Instruction
CMS-18F5 Application for Part A (Hospital Insurance)_Spanish CMS-18-F-5 (508)enabled Spanish.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Application for Part A (Hospital Insurance)	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 406.7 42 CFR 406.10 42 CFR 406.20 42 CFR 406.6 42 CFR 406.11

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	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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7,499	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	7,499	6,803	696
Annual IC Time Burden (Hours)	1,875	1,701	174
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.