Application for Enrollment in Medicare Part A, Internet Claim (iClaim) Application Screen, Modernized Claims System and Consolidated Claim (CMS-18F5)

OMB 0938-0251

The form CMS 18 (and 18SP) is used to establish entitlement to Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B) by individuals who do not qualify for entitlement based upon entitlement to a Social Security or Railroad Retirement benefits.

The latest form for Application for Enrollment in Medicare Part A, Internet Claim (iClaim) Application Screen, Modernized Claims System and Consolidated Claim (CMS-18F5) expires 2021-08-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-18F5 Application for Part A (Hospital Insurance) Form
Form CMS-18F5 Application for Part A (Hospital Insurance) Form
Form CMS-18F5 Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE)) Form and Instruction
Form CMS-18F5 Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE)) Form and Instruction
Form CMS-18F5 Internet Claim (iClaim) Application Form and Instruction
Form CMS-18F5 Internet Claim (iClaim) Application Form and Instruction
Non-sub Change Request Memo CMS 18F5.docx Justification for No Material/Nonsubstantive Change
Non-sub Change Request Memo CMS 18F5.docx Justification for No Material/Nonsubstantive Change
Crosswalk of Changes CMS 18F5 OMB 0938 0251.docx Supplementary Document
Crosswalk of Changes CMS 18F5 OMB 0938 0251.docx Supplementary Document
CMS-18F5 - Supporting Statement A - Clean.docx Supporting Statement A
CMS-18F5 - Supporting Statement A - Clean.docx Supporting Statement A
Justification for Collecting Social Security Numbers.pdf Supplementary Document
Justification for Collecting Social Security Numbers.pdf Supplementary Document
Application for Part A (Hospital Insurance) Form
Application for Part A (Hospital Insurance) Form
Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE)) Form and Instruction
Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE)) Form and Instruction
Internet Claim (iClaim) Application Form and Instruction
Internet Claim (iClaim) Application Form and Instruction

All Historical Document Collections

202304-0938-004 Approved with change	No material or nonsubstantive change to a currently approved collection	2023-04-11
202102-0938-008 Approved without change	Revision of a currently approved collection	2021-02-16
201804-0938-022 Approved with change	Reinstatement without change of a previously approved collection	2018-04-25
201402-0938-013 Approved without change	Extension without change of a currently approved collection	2014-02-26
201012-0938-021 Approved without change	Extension without change of a currently approved collection	2010-12-30
200708-0938-006 Approved without change	Extension without change of a currently approved collection	2007-08-15
200408-0938-003 Approved with change	Extension without change of a currently approved collection	2004-08-20
200107-0938-014 Approved without change	Extension without change of a currently approved collection	2001-07-26
199807-0938-015 Approved without change	Reinstatement without change of a previously approved collection	1998-07-24
199503-0938-003 Approved without change	Reinstatement without change of a previously approved collection	1995-03-09
199103-0938-006 Approved without change	Extension without change of a currently approved collection	1991-03-18
198908-0938-007 Approved without change	Extension without change of a currently approved collection	1989-08-31
198607-0938-003 Approved without change	Revision of a currently approved collection	1986-07-29
198408-0938-021 Approved with change	No material or nonsubstantive change to a currently approved collection	1984-08-13
198310-0938-027 Approved without change	Reinstatement with change of a previously approved collection	1983-10-19
198201-0938-006 Approved without change	Revision of a currently approved collection	1982-01-22