View Information Collection (IC)
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Agenda
Reg Review
ICR
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.