OMB control number
Application for Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease and Supporting Statute and Regulations in 42 CFR 406.7 and 406.13 (CMS-43)
OMB 0938-0080 · HHS/CMS.
OMB 0938-0080
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).
The latest form for Application for Part A (Hospital Insurance) and Part B (Medical Insurance) for People with End-Stage Renal Disease and Supporting Statute and Regulations in 42 CFR 406.7 and 406.13 (CMS-43) expires 2026-12-31 and is listed under ICR 202407-0938-001.
Latest Forms, Documents, and Supporting Material
| Document | Type |
|---|---|
 Form CMS-43 Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13 | Form |
 Supporting Statement A (CMS-43).docx | Supporting Statement A |
| Crosswalk of Changes CMS 43_508.pdf | Supplementary Document |
| Justification - Use of SSNs 0938-0080 CMS-43.pdf | Supplementary Document |
 Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13 |
Form |