Information Collection

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

IC 7901 under ICR 202608-0938-008 · OMB 0938-0245.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-4040 Request for Enrollment in Supplementary Medical Insurance Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40	Form and Instruction
CMS-4040 Request for Enrollment in Supplementary Medical Insuranc CMS-4040-rev.pdf	Form and Instruction
CMS 4040 Redline.pdf REDLINE: Request for Enrollment in Supplementary Medical Insurance	IC Document
Crosswalk of Changes CMS 4040 May 2026.pdf CROSSWALK: Request for Enrollment in Supplementary Medical 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 408.40 42 CFR 407.11 42 CFR 407.10

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-4040				Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 52,485

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	52,485	3,843	48,642
Annual IC Time Burden (Hours)	13,121	960	12,161
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
REDLINE: Request for Enrollment in Supplementary Medical Insurance		08/09/2026
CROSSWALK: Request for Enrollment in Supplementary Medical Insurance		08/09/2026

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

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