Information Collection

Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40

IC 7901 under ICR 202501-0938-011 · OMB 0938-0245.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
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
Form CMS-4040 Request for Enrollment in Supplementary Medical Insurance Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40	Form and Instruction
CMS-4040 Request for Enrollment in Supplementary Medical Insuranc CMS-4040 Redesigned.docx	Form and Instruction
CMS-4040 Request for Enrollment in Supplementary Medical Insuranc CMS-4040.docx	Form and Instruction
CMS-4040 Redlined.pdf Track Change	IC Document
CMS-4040 Redlined.pdf Track Change	IC Document

IC Title:

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 408.40 42 CFR 407.11 42 CFR 407.10

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-4040				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 48,642

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	48,642	6,631	42,011
Annual IC Time Burden (Hours)	12,161	1,658	10,503
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change		06/02/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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