OMB.report

Federal forms, ICRs, and supporting documents

OMB control number

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

OMB 0938-0245 · HHS/CMS.

OMB 0938-0245

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.

The latest form for Request for Enrollment in Supplementary Medical Insurance (SMI) (CMS-4040) expires 2028-07-31 and is listed under ICR 202501-0938-011.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form CMS-4040 Request for Enrollment in Supplementary Medical InsuranceForm and Instruction
Form CMS-4040 Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40Form and Instruction
Supporiting Statement A - CMS 4040 .docxSupporting Statement A
Supporiting Statement A - CMS 4040 .docxSupporting Statement A
Crosswalk of Changes CMS 4040_508.pdfSupplementary Document
Justification - Use of SSNs 0938-0245 CMS-4040.pdfSupplementary Document
Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 Form and Instruction
Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 Form and Instruction

All Historical Document Collections

Historical document collections
ReferenceFilingReceivedConcludedAction
202501-0938-011 Reinstatement with change of a previously approved collection 2025-03-28
202305-0938-014 Extension without change of a currently approved collection 2023-05-31 Approved without change
202003-0938-015 Extension without change of a currently approved collection 2020-03-24 Approved without change
201702-0938-004 Extension without change of a currently approved collection 2017-02-22 Approved without change
201309-0938-015 Reinstatement without change of a previously approved collection 2013-09-13 Approved without change
200811-0938-002 Extension without change of a currently approved collection 2008-11-04 Approved with change
200701-0938-015 Extension without change of a currently approved collection 2007-01-23 Approved without change
200304-0938-004 Extension without change of a currently approved collection 2003-04-11 Approved without change
200001-0938-004 Extension without change of a currently approved collection 2000-01-06 Approved without change
199610-0938-001 Reinstatement without change of a previously approved collection 1996-10-02 Approved without change
199109-0938-001 Extension without change of a currently approved collection 1991-09-25 Approved without change
199004-0938-004 Extension without change of a currently approved collection 1990-04-11 Approved without change
198703-0938-005 Revision of a currently approved collection 1987-03-16 Approved without change
198408-0938-008 Reinstatement with change of a previously approved collection 1984-08-30 Approved without change
198201-0938-007 Revision of a currently approved collection 1982-01-22 Approved without change