Information Collection

Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)

IC 240724 under ICR 202205-0938-003 · OMB 0938-1378.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1378 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	Form and Instruction
CMS-10718 Enrollment Form CMS 10718_CY 2023 Model MA PDP Indiv Enrollment Request Form.pdf	Form and Instruction
CMS-10718 Enrollment Form Model Indiv Enrollment Request Form OMB No. 0938-1378.pdf	Form and Instruction

IC Title:

Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.32(c)

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 and Instruction	CMS-10718	Enrollment Form	Model Indiv Enrollment Request Form OMB No. 0938-1378.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Advantage Prescription Drug (MARx) System

FR Citation: 83 FR 6591

Number of Respondents: 68

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	7,332,514	6,795,797	536,717
Annual IC Time Burden (Hours)	1,162,738	-106,086	1,268,824
Annual IC Cost Burden (Dollars)	0	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.