Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
Information Collection List
IC Title
Status
Responses
Hours
Dollars
Document Type
Form No.
Form Name
Application for Health Coverage and Help Paying Costs Short Form
New
258736
21561
0
Form and Instruction
CMS-10440
CMS-10440.AttachmentB-Application for Health Coverage & Help Paying Costs (Short Form)
Individual Application
New
2776698
1407261
0
Form and Instruction
CMS-10440
CMS-10440_AttachmentA-Individual Online Application Questionnaire
Form and Instruction
CMS-10440
AttachmentC-Application for Health Coverage & Help Paying Costs
Form and Instruction
CMS-10440
CMS_10440_AttachmentD-Application for Health Coverage
Total burden requested under this ICR:
3035434
1428822
0
To view an IC, click on IC Title
An official website of the United States government
The .gov means it's official.
The site is secure.
