Information Collection Request

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

ICR 202304-0938-004 · OMB 0938-0251 · Active

⚠️ Notice: This information collection may be outdated.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

Forms and Documents

Document	Type	Status	Availability
Form CMS-18F5 Application for Part A (Hospital Insurance)	Form	Modified	Available
Form CMS-18F5 Application for Part A (Hospital Insurance)	Form	Modified	Repair queued
Form CMS-18F5 Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE))	Form and Instruction	Unchanged	Repair queued
Form CMS-18F5 Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE))	Form and Instruction	Unchanged	Repair queued
Form CMS-18F5 Internet Claim (iClaim) Application	Form and Instruction	Modified	Available
Form CMS-18F5 Internet Claim (iClaim) Application	Form and Instruction	Modified	Repair queued
Non-sub Change Request Memo CMS 18F5.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-04-10	Repair queued
Non-sub Change Request Memo CMS 18F5.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2023-04-10	Missing upstream
Crosswalk of Changes CMS 18F5 OMB 0938 0251.docx	Supplementary Document	Uploaded 2023-04-10	Available
Crosswalk of Changes CMS 18F5 OMB 0938 0251.docx	Supplementary Document	Uploaded 2023-04-10	Repair queued
CMS-18F5 - Supporting Statement A - Clean.docx	Supporting Statement A	Uploaded 2021-05-25	Available
CMS-18F5 - Supporting Statement A - Clean.docx	Supporting Statement A	Uploaded 2021-05-25	Repair queued
Justification for Collecting Social Security Numbers.pdf	Supplementary Document	Uploaded 2021-02-12	Available
Justification for Collecting Social Security Numbers.pdf	Supplementary Document	Uploaded 2021-02-12	Repair queued

IC Document Collections

IC ID	Collection	Type	Status
7908	Application for Part A (Hospital Insurance)	Form	Modified
7908	Application for Part A (Hospital Insurance)	Form	Modified
245774	Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE))	Form and Instruction	Unchanged
245774	Interview/SSA Claim System (Modernized Claims System (MCS)/Consolidated Claim Experience (CCE))	Form and Instruction	Unchanged
245773	Internet Claim (iClaim) Application	Form and Instruction	Modified
245773	Internet Claim (iClaim) Application	Form and Instruction	Modified

ICR Details

Status	Active
Agency/Subagency	HHS/CMS
OMB Control No	0938-0251
Type of Information Collection	No material or nonsubstantive change to a currently approved collection
Previous ICR Reference No	202102-0938-008
Agency Tracking No	CM-CPC
Date Submitted to OIRA	2023-04-11
Requested Expiration Date	1969-12-31