Request for Enrollment in Supplementary Medical Insurance (SMI) (CMS-4040)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-4040 Request for Enrollment in Supplementary Medical Insurance	Form and Instruction	Modified	Repair queued
Form CMS-4040 Request for Enrollment in Supplementary Medical Insurance	Form and Instruction	Modified	Available
CMS-4040 Justification for Collecting Social Security Numbers (SSN) and Additional Information May 2026.pdf	Supplementary Document	Uploaded 2026-08-09	Repair queued
CMS-4040 Justification for Collecting Social Security Numbers (SSN) and Additional Information May 2026.pdf	Supplementary Document	Uploaded 2026-08-09	Available
CMS-4040 - Supporting Statement A (CMS-1848-P version 2).docx	Supporting Statement A	Uploaded 2026-08-09	Repair queued
CMS-4040 - 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
7901	Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40	Form and Instruction	Modified	Request for Enrollment in Supplementary Medical Insurance
7901	Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40	Form and Instruction	Modified	Request for Enrollment in Supplementary Medical Insurance

ICR Details

OMB Control No: 0938-0245	ICR Reference No: 202608-0938-008
Status: Historical Inactive	Previous ICR Reference No: 202501-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Request for Enrollment in Supplementary Medical Insurance (SMI) (CMS-4040)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 11/10/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/10/2026
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is not approved at this time. Prior to publication of the final rule, the agency should provide to OMB a summary of all comments received on the proposed information collection and identify any changes made in response to these comments.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2028	36 Months From Approved	07/31/2028
Responses	48,642	0	48,642
Time Burden (Hours)	12,161	0	12,161
Cost Burden (Dollars)	0	0	0

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Abstract: The form CMS 4040 is used to establish entitlement to Supplementary Medical Insurance (Part B) by individuals ineligible for Hospital Insurance (Part A) under Title XVIII of the Social Security Act. The CMS-4040SP is also included in this renewal.

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Authorizing Statute(s): Statute at Large: 18 Stat. 1836
   US Code: 42 USC 1395o Name of Law: Every individual who-
   Statute at Large: 18 Stat. 1840
  

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
Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40	CMS-4040	Request for Enrollment in Supplementary Medical Insurance

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: SSA is unable to share Calendar Year (CY) 2025 enrollment numbers of individuals utilizing CMS form 4040 with CMS. Therefore, the 2025 enrollment figure has been estimated using historical growth trends as a proxy. The projection for 2025 enrollment is based on the increase from 2022 (42,011) to 2024 (48,642), which represents a 15.8% growth over two years. This corresponds to an average annual growth rate of approximately 7.9%. Applying this annual rate to the 2024 enrollment, the figure is multiplied by 1.079 to estimate 2025 enrollment, resulting in an increase of 3,843 applications (from 48,642 [active] to 52,485 [proposed]). Consistent with our active 0.25 hour response time, results in an increase of 960 hours (from 12,161 hr [active] to 13,121 hr [proposed]).

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Annual Cost to Federal Government: $454,511

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.     No

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.     No

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: 08/10/2026

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