Information Collection

Internet Claim (iClaim) Application

IC 245773 under ICR 202506-0938-008 · OMB 0938-0251.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-18F5 Internet Claim (iClaim) Application	Form and Instruction
Form CMS-18F5 iClaim SEP Screens Internet Claim (iClaim) Application	Form and Instruction
Form CMS-18F5 CAA - SEP UI Mock-ups Internet Claim (iClaim) Application	Form and Instruction
CMS-18F5 iClaim SEP Screens Proposed iClaim SEP Screens 10052022.docx	Form and Instruction
CMS-18F5 iClaim SEP Screens Proposed iClaim SEP Screens 10052022.docx	Form and Instruction
CMS-18F5 CAA - SEP UI Mock-ups Proposed CAA - SEP UI Mock-ups -.docx	Form and Instruction
CMS-18F5 CAA - SEP UI Mock-ups Proposed CAA - SEP UI Mock-ups -.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 406.10 42 CFR 406.11 42 CFR 406.20 42 CFR 406.6, , 42 CFR 406.7,

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-18F5				Yes	Yes	Fillable Fileable
Form and Instruction	CMS-18F5				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,134,262

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	Previously Approved
Annual Number of Responses for this IC	1,134,262	1,134,262
Annual IC Time Burden (Hours)	283,565	283,565
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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