View Information Collection (IC)

View Information Collection (IC)

IC Title:	Individual Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR Parts 155, 156, 157 42 CFR Parts 431, 435, 457 26 CFR 1 and 602 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10440	CMS-10440_AttachmentA-Individual Online Application Questionnaire	CMS-10440.AttachmentA-Individual Online Application Questionnaire.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10440	AttachmentC-Application for Health Coverage & Help Paying Costs	CMS-10440.AttachmentC-Application for Health Coverage & Help Paying Costs.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-10440	CMS_10440_AttachmentD-Application for Health Coverage	CMS-10440.AttachmentD-Application for Health Coverage.pdf		Yes	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,776,698	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	2,776,698	2,776,698	0	0	0	0
Annual IC Time Burden (Hours)	1,407,261	1,407,261	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	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.