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Federal forms, ICRs, and supporting documents

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
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 408.40 42 CFR 407.11 42 CFR 407.10

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-4040 Request for Enrollment in Supplementary Medical Insurance CMS-4040.docx Yes Yes Fillable Printable

Health Health Care Services

 

48,642 0
   
Individuals or Households
 
   0 %

  Approved 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 48,642 0 0 6,631 42,011 0
Annual IC Time Burden (Hours) 12,161 0 0 1,658 10,503 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Track Change CMS-4040 Redlined.pdf 06/02/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.