Information Collection

Application for Enrollment in Medicare Part B (Medical Insurance)

IC 209928 under ICR 202501-0938-012 · OMB 0938-1230.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-40B (SP) Application for Enrollment in Medicare Part B (Medical Insurance)	Form and Instruction
Form CMS-40B (SP) Solicitud De Inscripcion En La Parte De Medicare (Seguro Medico) Application for Enrollment in Medicare Part B (Medical Insurance)	Form and Instruction
Form CMS-40B Application for Enrollment in Medicare Part B (Medical Insurance) Application for Enrollment in Medicare Part B (Medical Insurance)	Form and Instruction
Form CMS-40B Enrollment Screenshots Application for Enrollment in Medicare Part B (Medical Insurance)	Form and Instruction
CMS-40B Telephonic Attestation.docx	Instruction
CMS-40B Telephonic Attestation.docx	Instruction
CMS-40B (SP) Solicitud De Inscripcion En La Parte De Medicare (Seguro Spanish_CMS-40B_508_Enabled revised.pdf www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf	Form and Instruction
CMS-40B (SP) Solicitud De Inscripcion En La Parte De Medicare (Seguro Spanish_CMS-40B_508_Enabled revised.pdf www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf	Form and Instruction
CMS-40B Application for Enrollment in Medicare Part B (Medical I CMS-40B-2024 Redesign_.docx	Form and Instruction
CMS-40B Application for Enrollment in Medicare Part B (Medical I CMS-40B-051525.docx	Form and Instruction
CMS-40B Enrollment Screenshots Enrollment Screenshots for CMS-40B.docx	Form and Instruction
CMS-40B Enrollment Screenshots Enrollment Screenshots for CMS-40B.docx	Form and Instruction
CMS-40B Current form redlined (1).pdf Track Change - CMS-40B	IC Document
CMS-40B Current form redlined (1).pdf Track Change - CMS-40B	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Application for Enrollment in Medicare Part B (Medical 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:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-40B (SP)	https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-S.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-40B		Yes	No	Fillable Printable
Instruction			Yes	Yes	Printable Only
Form and Instruction	CMS-40B		Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,184,546

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

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	1,184,546	115,831	1,068,715
Annual IC Time Burden (Hours)	292,820	27,532	265,288
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change - CMS-40B		03/21/2025

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

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