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 (SMI) (CMS-4040)

Documents and Forms

Document Name Document Type
Form CMS-4040 Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40 Form and Instruction
CMS-4040 Request for Enrollment in Supplementary Medical Insuranc CMS-4040 Redesigned.docx Form and Instruction
CMS-4040 Redlined.pdf Track Change IC Document

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:	CM-CPC

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 408.40 42 CFR 407.11 42 CFR 407.10

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-4040	Request for Enrollment in Supplementary Medical Insurance	CMS-4040 Redesigned.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 48,642	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	48,642	6,631	42,011
Annual IC Time Burden (Hours)	12,161	1,658	10,503
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Track Change	CMS-4040 Redlined.pdf	01/23/2025

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