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

Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 (CMS-4040)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0245 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-4040SP Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 Form and Instruction
CMS-4040SP Petici?n Para Inscribirse En El Seguro Medico Suplementa CMS-4040SP [rev OSORA PRA].pdf Form and Instruction
CMS-4040 Request for Enrollment in Supplementary Medical Insuranc CMS-4040 [rev OSORA PRA].pdf Form and Instruction

Information Collection (IC) Details

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

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-4040SP	Petici?n Para Inscribirse En El Seguro Medico Suplementario	CMS-4040SP [rev OSORA PRA].pdf		Yes	Yes	Fillable Printable
Form and Instruction	CMS-4040	Request for Enrollment in Supplementary Medical Insurance	CMS-4040 [rev OSORA PRA].pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 47,200	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	47,200	37,200	10,000
Annual IC Time Burden (Hours)	11,800	9,300	2,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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