Information Collection

Application for Part A (Hospital Insurance)

IC 7908 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 Application for Part A (Hospital Insurance)	Form and Instruction
Form CMS-18F5 Application for Part A (Hospital Insurance) Application for Part A (Hospital Insurance)	Form and Instruction
Form CMS-18F5 Application for Part A (Hospital Insurance)_Spanish Application for Part A (Hospital Insurance)	Form and Instruction
CMS-18F5 Application for Part A (Hospital Insurance) CMS-18-F-5-052825.docx	Form and Instruction
CMS-18F5 Application for Part A (Hospital Insurance) CMS-18-F-5-052825.docx	Form and Instruction
CMS-18F5 Application for Part A (Hospital Insurance)_Spanish CMS-18-F-5 (508)enabled Spanish.docx	Form and Instruction
CMS-18F5 Application for Part A (Hospital Insurance)_Spanish CMS-18-F-5 (508)enabled Spanish.docx	Form and Instruction
CMS-18-F-5-Redline.pdf Track Change - Application for Medicare Part A (Hospital Insurance)	IC Document
CMS-18-F-5-Redline.pdf Track Change - Application for Medicare Part A (Hospital Insurance)	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 406.10 42 CFR 406.20 42 CFR 406.6 42 CFR 406.11 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	No	Fillable Printable
Form and Instruction	CMS-18F5				Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 7,499

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	Previously Approved
Annual Number of Responses for this IC	7,499	7,499
Annual IC Time Burden (Hours)	1,875	1,875
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change - Application for Medicare Part A (Hospital Insurance)		06/12/2025

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

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