Information Collection

Application for Hospital Insurance and Supporting Regulations in 42 CFR 406.6, 406.7,406.10,406.11 and 406.20

IC 7908 under ICR 201402-0938-013 · OMB 0938-0251.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0251 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-18F5 (SP) Application for Hospital Insurance and Supporting Regulations in 42 CFR 406.6, 406.7,406.10,406.11 and 406.20 Form
CMS-18F5 (SP) SOLICITUD PARA EL SEGURO DE HOSPITAL CMS-18F5_SP(508).pdf Form
CMS-18F5 APPLICATION FOR HOSPITAL INSURANCE CMS-18F5(508)_(2).pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application for Hospital Insurance and Supporting Regulations in 42 CFR 406.6, 406.7,406.10,406.11 and 406.20	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 406.7 42 CFR 406.6 42 CFR 406.10 42 CFR 406.11 42 CFR 406.20

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-18F5 (SP)	SOLICITUD PARA EL SEGURO DE HOSPITAL	CMS-18F5_SP(508).pdf		Yes	Yes	Fillable Printable
Form	CMS-18F5	APPLICATION FOR HOSPITAL INSURANCE	CMS-18F5(508)_(2).pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 50,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	50,000	0	50,000
Annual IC Time Burden (Hours)	12,500	5	12,495
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.