Information Collection Request
Request for Enrollment in Supplementary Medical Insurance (SMI) (CMS-4040)
ICR 202501-0938-011 · OMB 0938-0245 · Received in OIRA
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 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 | Repair queued |
 Supporiting Statement A - CMS 4040 .docx |
Supporting Statement A | Uploaded 2025-03-21 | Repair queued |
 Crosswalk of Changes CMS 4040_508.pdf |
Supplementary Document | Uploaded 2025-01-23 | Repair queued |
| Justification - Use of SSNs 0938-0245 CMS-4040.pdf |
Supplementary Document | Uploaded 2017-02-17 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 7901 |  Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-0245 |
| Type of Information Collection | Reinstatement with change of a previously approved collection |
| Previous ICR Reference No | 202305-0938-014 |
| Agency Tracking No | CM-CPC |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |