CMS-10797 CMS 10797 Application for Part A and Part B Special Enro

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

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

APPLICATION FOR MEDICARE PART A AND PART B SPECIAL ENROLLMENT PERIOD (EXCEPTIONAL CIRCUMSTANCES)
WHAT IS THE PURPOSE OF THIS FORM?
If you didn’t sign up for Medicare Premium Part A or Part B during your Initial Enrollment Period (IEP), you can sign up without
a late enrollment penalty during a Special Enrollment Period (SEP). If you think that you may be eligible for a SEP, please
contact Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

WHAT INFORMATION DO YOU NEED TO COMPLETE THIS FORM?
You will need:
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Your Medicare Number or Social Security number (SSN)
Your current address and phone number
Qualifying documentation of eligibility for the SEP

HOW DO YOU SUBMIT THE FORM?
Complete and sign page 2 of the form and send it to your local Social Security field office

HOW DO YOU GET HELP WITH THIS FORM?
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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/locator.
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.

TELL US ABOUT YOURSELF: We need this information to find you in our records.
1.Your Social Security Number (or your Medicare Number,
if you already have Part B )

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2. Your Name (Last Name, First Name, Middle Name)

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3. Name at Birth if different than item 1b

4. Sex
Male

5. Date of Birth (MM/DD/YYYY)

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Female

6. State or Country of Birth (NO abbreviations)
8. Address of permanent residence, if different from your
mailing address

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7. Mailing Address (Number and Street, P.O Box, or Route)
9. Phone Number

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SPECIAL ENROLLMENT PERIOD (EXCEPTIONAL CIRCUMSTANCES):
Based on the descriptions below, please select the SEP that you believe best fits your situation. If none apply, please contact
SSA to see if there are other available options.
SEP FOR INDIVIDUALS IMPACTED BY AN EMERGENCY OR NATURAL DISASTER
Dates of the declared emergency (The declaration must be on or after January 1, 2023):
Start Date:

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Ending Date:

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Select this SEP if you have proof of the following:
• You reside (or resided) in an area for which a Federal, state or local government entity declared a disaster or other
emergency.
• You were in your IEP, General Enrollment Period (GEP), or another SEP and were not able to enroll in Medicare as a
result of a disaster or other emergency declared by a Federal, state or local government entity.
• Proof of eligibility for the SEP
SEP FOR GROUP HEALTH PLAN (GHP) OR EMPLOYER MISREPRESENTATION
Select this SEP you have proof of ALL of the following
• On or after January 1, 2023
• On or after January 1, 2023 you did not enroll in Part B during your IEP, GEP, or another SEP due to misinformation
provided by your employer or GHP.
• You have documented evidence of the misinformation that is directly from your employer or GHP. The evidence shows
that the misinformation was provided prior to the end of your IEP or another SEP.
SEP TO COORDINATE WITH TERMINATION OF MEDICAID COVERAGE
Select this SEP if both apply:
• You are currently eligible for Medicare.
• You are either currently eligible for Medicaid or have lost Medicaid eligibility on or after January 1, 2023, or the last
day of the COVID-19 PHE, whichever is earlier.
SEP FOR FORMERLY INCARCERATED INDIVIDUALS
Date of Incarceration:

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Date of Release
(on of after January 1, 2023):

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Select this SEP if you were released within the last 3 months and ANY of the following apply:
• Your Medicare was terminated due to non-payment of premiums while you were incarcerated (meaning the individual is
in custody of penal authorities as defined in 42 CFR §411.4(b).
• You voluntarily terminated your coverage while incarcerated.
• You became eligible for Premium Part A or Part B, while incarcerated.
*Individuals who are in custody include, but are not limited to, individuals who are under arrest, incarcerated, imprisoned,
escaped from confinement, under supervised release, on medical furlough, required to reside in mental health facilities,
required to reside in halfway houses, required to live under home detention, or confined completely or partially in any
way under a penal statute or rule.
SEP FOR OTHER EXCEPTIONAL CIRCUMSTANCES
Select this SEP if you have a different exceptional circumstance that occurred on or after January 1, 2023 and is not listed
above. You must have proof of the following:
• You experienced circumstances outside of your control caused you to miss your IEP, GEP, or another SEP.

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SIGN YOUR APPLICATION
I know that anyone who makes or causes to be made a false statement or representation of material fact in an application or
for use in determining a right to Medicare coverage under the Social Security Act commits a crime punishable under Federal
law by fine, imprisonment or both. I affirm that all information I have given in this document is true.1
Signature (Do not print)

Date Signed

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If this application has been signed by mark (X), a witness who knows the person applying must also sign this form.
Name of witness (first and last name) (Printed)
Witness (Signature):

Date Signed

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Witness Address:

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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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