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OMB Control No: 0938-0245	ICR Reference No: 202608-0938-008
Status: Received in OIRA	Previous ICR Reference No: 202501-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Request for Enrollment in Supplementary Medical Insurance (SMI) (CMS-4040)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 08/10/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2028
Responses	52,485	48,642
Time Burden (Hours)	13,121	12,161
Cost Burden (Dollars)	0	0

Abstract: The form CMS 4040 is used to establish entitlement to Supplementary Medical Insurance (Part B) by individuals ineligible for Hospital Insurance (Part A) under Title XVIII of the Social Security Act. The CMS-4040SP is also included in this renewal.

Authorizing Statute(s): Statute at Large: 18 Stat. 1836
   US Code: 42 USC 1395o Name of Law: Every individual who-
   Statute at Large: 18 Stat. 1840

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AV82	Proposed rulemaking	91 FR 43842	07/16/2026

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 43842	07/16/2026
Did the Agency receive public comments on this ICR? No

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for Enrollment in Supplementary Medical Insurance and Supporting Regs in 42 CFR 407.10, 407.11 & 408.40	CMS-4040

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	52,485	48,642	3,843
Annual Time Burden (Hours)	13,121	12,161	960
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: SSA is unable to share Calendar Year (CY) 2025 enrollment numbers of individuals utilizing CMS form 4040 with CMS. Therefore, the 2025 enrollment figure has been estimated using historical growth trends as a proxy. The projection for 2025 enrollment is based on the increase from 2022 (42,011) to 2024 (48,642), which represents a 15.8% growth over two years. This corresponds to an average annual growth rate of approximately 7.9%. Applying this annual rate to the 2024 enrollment, the figure is multiplied by 1.079 to estimate 2025 enrollment, resulting in an increase of 3,843 applications (from 48,642 [active] to 52,485 [proposed]). Consistent with our active 0.25 hour response time, results in an increase of 960 hours (from 12,161 hr [active] to 13,121 hr [proposed]).

Annual Cost to Federal Government: $454,511

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

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