Application for Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13 (CMS-43)

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 Hospital Insurance Benefits Medicare for Individuals with End Stage Renal Disease and Supporting Regulations in 42 CFR 406.7 and 406.13 (CMS-43) expires 2021-02-28 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
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
CMS-43 - Supporting Statement A.docx Supporting Statement A
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

All Historical Document Collections

202101-0938-007 Approved without change	Extension without change of a currently approved collection	2021-01-15
201707-0938-008 Approved with change	Reinstatement without change of a previously approved collection	2017-07-19
201311-0938-008 Approved without change	Reinstatement without change of a previously approved collection	2013-11-08
200908-0938-009 Approved without change	Extension without change of a currently approved collection	2009-08-19
200701-0938-018 Approved without change	Extension without change of a currently approved collection	2007-01-29
200306-0938-002 Approved without change	Extension without change of a currently approved collection	2003-06-04
200002-0938-007 Approved without change	Extension without change of a currently approved collection	2000-02-24
199609-0938-003 Approved without change	Reinstatement without change of a previously approved collection	1996-09-04
199404-0938-002 Approved without change	Reinstatement with change of a previously approved collection	1994-04-25
199012-0938-014 Approved without change	Extension without change of a currently approved collection	1990-12-20
198901-0938-007 Approved without change	Reinstatement with change of a previously approved collection	1989-01-11
198504-0938-009 Approved without change	Revision of a currently approved collection	1985-04-29
198206-0938-005 Approved without change	Revision of a currently approved collection	1982-06-07
197808-0938-001 Approved without change	New collection (Request for a new OMB Control Number)	1978-08-16