Form CMS-10718 Enrollment Form

OMB No. 0938-NEW
Expires:XX/XX

EXHIBIT 1: MODEL INDIVIDUAL ENROLLMENT REQUEST FORM TO
ENROLL IN A MEDICARE ADVANTAGE PLAN (PART C) OR
MEDICARE PRESCRIPTION DRUG PLAN (PART D)
Who can use this form?

Reminders:

People with Medicare who want to join a Medicare
Advantage Plan or Medicare Prescription Drug Plan

•

To join a plan, you must:
• Be a United States citizen or be lawfully
present in the U.S.
• Live in the plan’s service area
Important: To join a Medicare Advantage Plan,
you must also have both:
• Medicare Part A (Hospital Insurance)
• Medicare Part B (Medical Insurance)

When do I use this form?
You can join a plan:
• Between October 15–December 7 each year (for
coverage starting January1)
• Within 3 months of first getting Medicare
• In certain situations where you’re allowed to
join or switch plans
Visit Medicare.gov to learn more about when you
can sign up for a plan.

What do I need to complete this form?
•
•

Your Medicare Number (the number on your
red, white, and blue Medicare card)
Your permanent address and phone number

Note: You must complete all items in Section 1.
The items in Section 2 are optional — you can’t be
denied coverage because you don’t fill them out.

•

If you want to join a plan during fall open
enrollment (October 15–December 7), the plan
must get your completed form by December 7.
Your plan will send you a bill for the plan’s
premium. You can choose to sign up to have
your premium payments deducted from your
bank account or your monthly Social Security
(or Railroad Retirement Board) benefit.

What happens next?
Send your completed and signed form to:

Once they process your request to join, they’ll
contact you.

How do I get help with this form?
Call at . TTY users
can call < phone number >.
Or, call Medicare at 1-800-MEDICARE
(1-800-633-4227). TTY users can call
1-877-486-2048.
En español: Llame a al o a Medicare gratis al
1-800-633-4227 y oprima el 2 para asistencia en
español y un representante estará disponible para
asistirle.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-NEW. The time required to complete this information is estimated to average 20 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy
of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.
IMPORTANT
Do not send this form or any items with your personal information (such as claims, payments, medical records, etc.) to the PRA Reports Clearance Office. Any items we
get that aren’t about how to improve this form or its collection burden (outlined in PMB 0939-XXXX) will be destroyed. It will not be kept, reviewed, or forwarded to the
plan. See “What happens next?” on this page to send your completed form to the plan.

OMB No. 0938-XXXX
Expires:XX/XX

Section 1 – All fields on this page are required (unless marked optional)
Select the plan you want to join:
Product ABC – $XX per month
FIRST name:

LAST name:

Birth date: (MM/DD/YYYY)
Sex:
(__ __/__ __/__ __ __ __)
Male
Female
Permanent Residence street address (Don’t enter a PO Box):
City:

Product XYZ – $XX per month
[Optional: Middle Initial]:
Phone number:
(
)

[Optional: County]:

State:

Mailing address, if different from your permanent address (PO Box allowed):
Street address:
City:
State:
Your Medicare information:
Medicare Number:
____-___-____

ZIP Code:
ZIP Code:

Answer these important questions:
[MA-PD / PDPs insert:
Will you have other prescription drug coverage (like VA, TRICARE) in addition to < Plan>?
Name of other coverage:
___________________________

Member number for this coverage:
____________________________

Yes

No

Group number for this coverage
________________________]

[Special Needs Plans] insert question(s) regarding the required special needs criteria]
IMPORTANT: Read and sign below:
• [MA plans insert: I must keep both Hospital (Part A) and Medical (Part B) to stay in .]
• [Part D plans insert: I must keep Hospital (Part A) or Medical (Part B) to stay in .]
• By joining this Medicare Advantage Plan or Medicare Prescription Drug Plan, I acknowledge that will share my information with Medicare, who may use it to track my enrollment, to make payments,
and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy
Act Statement below).
• Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
• The information on this enrollment form is correct to the best of my knowledge. I understand that if I
intentionally provide false information on this form, I will be disenrolled from the plan.
• I understand that people with Medicare are generally not covered under Medicare while out of the country,
except for limited coverage near the U.S. border.
• [MA plans insert: I understand that when my coverage begins, I must get all of my medical and
prescription drug benefits from . Benefits and services provided by and contained
in my “Evidence of Coverage” document (also known as a member contract or subscriber
agreement) will be covered. Neither Medicare nor will pay for benefits or services that are not
covered.]
• I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this
application means that I have read and understand the contents of this application. If signed by an authorized
representative (as described above), this signature certifies that:
1) This person is authorized under State law to complete this enrollment, and
2) Documentation of this authority is available upon request by Medicare.
Signature:
Today’s date:
If you’re the authorized representative, sign above and fill out these fields:
Name:

Address:

Phone number:

Relationship to enrollee:

OMB No. 0938-XXXX
Expires:XX/XX

Section 2 – All fields on this page are optional
Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.
Select one if you want us to send you information in a language other than English.
[ Plans insert the languages required in your service area.]
Select one if you want us to send you information in an accessible format.
Braille
Large print
Audio CD
Please contact at if you need information in an accessible format other than
what’s listed above. Our office hours are . TTY users can call
Do you work?

Yes

No

Does your spouse work?

Yes

No

List your Primary Care Physician (PCP), clinic, or health center:
I want to get the following materials via email. Select one or more.
[Plans may list those types or categories of materials that are available for electronic delivery]
E-mail address:

Paying your plan premiums
[Plans with premiums insert: You can pay your monthly plan premium [MA-PD plans with premiums insert:
(including any late enrollment penalty that you currently have or may owe)] by mail each month . You can also choose to pay your premium by having it automatically taken out of
your Social Security or Railroad Retirement Board (RRB) benefit each month.]
[MA-PD and PDPs with premiums insert: If you have to pay a Part D-Income Related Monthly Adjustment
Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium. The amount
is usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON’T
pay [insert appropriate plan and/or organization name] the Part D-IRMAA.]
PRIVACY ACT STATEMENT
The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) or Prescription Drug
Plans (PDP), improve care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50, 422.60, 423.30 and 423.32
authorize the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the System of Records Notice (SORN)
“Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.