Information Collection

Special Enrollment Periods

IC 235622 under ICR 201904-0938-006 · OMB 0938-1207.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1207 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10468 Special Enrollment Periods	Form
CMS-10468 Appendix A - Enrollment Notices CMS-10468 - Appendix A - Enrollment Notices.pdf	Form

IC Title:

Special Enrollment Periods

Agency IC Tracking Number:

10468

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 45 CFR 155.420

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10468	Appendix A - Enrollment Notices	CMS-10468 - Appendix A - Enrollment Notices.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,700

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	4,700	4,700
Annual IC Time Burden (Hours)	4,700	4,700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.