Request for Enrollment in Supplementary Medical Insurance (SMI) (CMS-4040)

ICR 202501-0938-011

OMB: 0938-0245

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-4040 Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 Form and Instruction	Modified
Supporiting Statement A - CMS 4040 .docx Supporting Statement A	2025-03-21
Crosswalk of Changes CMS 4040_508.pdf Supplementary Document	2025-01-23
Justification - Use of SSNs 0938-0245 CMS-4040.pdf Supplementary Document	2017-02-17

IC Document Collections

IC ID	Document Title	Status
7901	Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 Form and Instruction	Modified