Form CMS-10798 Application for Part B Immunosuppressive Drug

Form Approved
OMB No. 0938-xxxx
Expires:xx/xx

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

APPLICATION FOR ENROLLMENT IN PART B IMMUNOSUPPRESSIVE DRUG COVERAGE
WHAT IS PART B IMMUNOSUPPRESSIVE DRUG
COVERAGE (PART B-ID)?
The Part B-ID benefit coverage is only available to individuals
who are entitled to Medicare based on End-Stage Renal
Disease (ESRD) and are losing Medicare entitlement 36
months after a successful kidney transplant. The benefit
is coverage soley for immunosuppressive drugs under
Medicare Part B.

WHO CAN USE THIS FORM?
Use this form if you or your child/dependent had a
successful kidney transplant and have lost or will be losing
their Medicare coverage that was based on ESRD 36 months
after their successful kidney transplant.
NOTE: If you or your child/dependent have other health
coverage, or you or your child/dependent have Medicaid or
State Children’s Health Insurance Program (CHIP) that covers
immunosuppressive drugs, do not complete this form.

WHEN DO YOU USE THIS FORM?
You should use this form:
• If you or your child/dependent have lost or will be losing
Medicare coverage that was based on ESRD 36 months
after a successful kidney transplant, and you/they
want to enroll in the Part B-ID benefit for coverage of
immunosuppressive drugs.
• If you or your child/dependent are not enrolled in any
other health insurance coverage (except Medicaid or CHIP
that does not cover immunosuppressive drugs).
• If you or your child/dependent do not expect to enroll in
any other health insurance coverage (except Medicaid or
CHIP that does not cover immunosuppressive drugs).

WHEN CAN YOU ENROLL?
Enrollment in Part B-ID can begin two months prior to the
termination of your Medicare based on ESRD or anytime
after ESRD termination. If you enroll prior to the termination
of your Medicare based on ESRD, your Part B-ID benefit will
begin the month after ESRD Medicare termination. If you
enroll in Part B-ID after your ESRD Medicare termination, Part
B-ID will begin the month following the enrollment.

WHAT INFORMATION DO YOU NEED TO
COMPLETE THIS FORM?
• Applicant’s Medicare Number or Social Security Number
• Applicant’s current address and phone number

HOW DO YOU SUBMIT THE FORM?
Complete and sign page 2 of this form and send it to
your local Social Security office. If you have questions
call Social Security at 1-800-772-1213. TTY users can call
1-800-325-0778. You can also apply for this benefit by calling
1-800-xxx-xxxx

HOW DO YOU GET HELP WITH THIS FORM?
• Call Social Security at 1-800-772-1213. TTY users can call
1-800-325-0778.
• Contact your local field office. Find an office near you
at www.ssa.gov.
• En español: Llame a SSA gratis al 1-800-772-1213 y oprima
el 7 si desea el servicio en español y espere a que le
atienda un agente.

• You do not currently have Medicare based on being age
65 or older or based on having a disability.

WHEN TO NOTIFY SSA
NOTE: If you enroll in any other health insurance coverage,
you must notify the Social Security Administration (SSA)
within 60 days of obtaining other health insurance coverage.
Other health insurance coverage may include:
• Group Health Plan or Individual Health Plan
• Marketplace
• TRICARE for Life
• Medicaid or CHIP coverage that includes
immunosuppressive drugs
• Enrolled in the patient enrollment system of the
Department of Veterans Affairs (VA) or otherwise eligible
to receive immunosuppressive drugs from the VA.

CMS-10798 (xx/xx)

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Form Approved
OMB No. 0938-XXXX
Expires: XX/XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

APPLICATION FOR ENROLLMENT IN PART B IMMUNOSUPPRESSIVE DRUG COVERAGE
1. Medicare Number/SSN
2. Your Name (Last Name, First Name, Middle Name)

3. Mailing Address (Number and Street, P.O. Box, or Route)

City

State

Zip Code

State

Zip Code

4. Permanent Address (if different from mailing address)

City

5. Phone Number (including area code)

(

)

–

By using this form to enroll in the Part B-ID benefit for immunosuppressive drug coverage I attest that:
Yes

No I am not enrolled in, and do not expect to enroll in, other health insurance coverage, and
I will notify Social Security within 60 days if I enroll in other health insurance coverage.

*Please refer to page 1 for a description of other health insurance coverage.
I understand that anyone who, knowingly and willfully —
(1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact;
or
(2) makes any materially false, fictitious, or fraudulent statements or representations, or makes or uses any
materially false writing or document knowing the same to contain any materially false, fictitious, or fraudulent
statement or entry, in connection with the delivery of or payment for health care benefits, items, or services,
shall be fined or imprisoned not more than 5 years, or both.1
Signature (DO NOT PRINT)
SIGN HERE

Date Signed

/

/

IF THIS APPLICATION HAS BEEN SIGNED BY MARK (X), A WITNESS WHO KNOWS THE APPLICANT
MUST SUPPLY THE INFORMATION REQUESTED BELOW.
Signature of Witness

Date Signed

/

/

Address of Witness

18 U.S. Code § 1035 - False statements relating to health care matters
(a) Whoever, in any matter involving a health care benefit program, knowingly and willfully—
(1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact;
or
(2) makes any materially false, fictitious, or fraudulent statements or representations, or makes or uses any materially false writing or
document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry, in connection with the delivery
of or payment for health care benefits, items, or services, shall be fined under this title or imprisoned not more than 5 years, or both.
(b) As used in this section, the term “health care benefit program” has the meaning given such term in section 24(b) of this title.
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CMS-10798 (xx/xx)

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Form Approved
OMB No. 0938-XXXX
Expires: XX/XX

STEP BY STEP INSTRUCTIONS FOR FILLING OUT THIS APPLICATION
1. Applicant’s social security number (or applicant’s Medicare Number): Enter your Social Security Number, or if you already
have Medicare, you can enter your Medicare Number instead.
2. Name: Enter your name. List your last name, first name, and middle name (if you have one) in that order.
3. Mailing address: Enter your full mailing address, including the number and street name, city, state, and ZIP code. You can
enter a P.O. Box or route.
4. Address of permanent residence: If you live at a different address than where you get mail, enter the full address,
including the number and street name, city, state and ZIP code.
5. Phone number: Enter your daytime phone number in case a representative needs to contact you for additional
information.
Enrollment in the Part B-ID Benefit
Check the box to attest that you meet the requirements for entitlement to the Part B-ID benefit.
Refer to page 1 under the description of Other Health Insurance Coverage.

PRIVACY ACT STATEMENT: Social Security is authorized to collect your information under sections 1836, 1840, and 1872 of the Social Security
Act, as amended (42 U.S.C. 1395o, 1395s, and 1395ii) for your enrollment in Medicare Part B. Social Security and the Centers for Medicare &
Medicaid Services (CMS) need your information to determine if you’re entitled to Part B. While you don’t have to give your information, failure to
give all or part of the information requested on this form could delay your application for enrollment.
Social Security and CMS will use your information to enroll you in Part B. Your information may be also be used to administer Social Security or
CMS programs or other programs that coordinate with Social Security or CMS and in accordance with System of Records Notice (SORN) “HHS/
CMS/CBC Enrollment Database”, System No. 09-70-0502, 73 Federal Register 10249, February 26th, 2008 and as permitted by the Privacy Act of
1974, to:
1) Determine your rights to Social Security benefits and/or Medicare coverage.
2) Comply with Federal laws requiring Social Security and CMS records (like to the Government Accountability Office and the Veterans
Administration)
3) Assist with research and audit activities necessary to protect integrity and improve Social Security and CMS programs (like to the Bureau of
the Census and contractors of Social Security and CMS). We may verify your information using computer matches that help administer Social
Security and CMS programs in accordance with the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503).
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