Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)

Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form (CMS-10718)

OMB: 0938-1378

IC ID: 240724

Information Collection (IC) Details

View Information Collection (IC)

Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 423.32(c)

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

Health Health Care Services

Medicare Advantage Prescription Drug (MARx) System  83 FR 6591

68 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  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 7,332,514 0 0 6,795,797 0 536,717
Annual IC Time Burden (Hours) 1,162,738 0 0 -106,086 0 1,268,824
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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