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

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 2023-06-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
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
Supporiting Statement A - CMS 4040 .docx Supporting Statement A
Crosswalk of Changes CMS 4040_508.pdf Supplementary Document
Justification - Use of SSNs 0938-0245 CMS-4040.pdf Supplementary Document
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All Historical Document Collections

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