Application for Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease (CMS-43)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-43 Application for Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) for People with End-Stage Renal Disease	Form and Instruction	Modified	Available
CMS-43 Justification for Collection Social Security Numbers April 2026_508 .pdf	Supplementary Document	Uploaded 2026-08-09	Available
CMS-43 - Supporting Statement A (CMS-1848-P version 2).docx	Supporting Statement A	Uploaded 2026-08-09	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7835	Application for Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease	Form and Instruction	Modified	Application for Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) for People with End-Stage Renal Disease

ICR Details

OMB Control No: 0938-0080	ICR Reference No: 202608-0938-001
Status: Received in OIRA	Previous ICR Reference No: 202407-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Application for Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease (CMS-43)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/30/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2026
Responses	45,200	45,200
Time Burden (Hours)	18,984	18,984
Cost Burden (Dollars)	0	0

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Abstract: The CMS-43 form is used to establish entitlement to Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B) by individuals with End Stage Renal Disease (ESRD).

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Authorizing Statute(s): US Code: 42 USC 426-1 Name of Law: Special Provisions Relating to Coverage Under Medicare Program for End Stage Renal Disease
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV82	Proposed rulemaking	91 FR 43842	07/16/2026

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 43842	07/16/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Application for Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease	CMS-43	Application for Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) for People with End-Stage Renal Disease

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	45,200	45,200	0	0	0	0
Annual Time Burden (Hours)	18,984	18,984	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,174,296

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/30/2026

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