Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)

Application For Medicare Part A and Part B Special Enrollment Period - Exceptional Circumstances (CMS-10797)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1426 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10797 Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) Form and Instruction
CMS-10797 CMS 10797 Application for Part A and Part B Special Enro CMS 10797 Application for Part A and Part B Special Enrollment Period Exceptional Circumstances_508.pdf Form and Instruction
CMS-10797 CMS 10797 Application for Part A and Part B Special Enro CMS 10797 Application for Part A and Part B Special Enrollment Period Exceptional Circumstances_508.pdf Form and Instruction
CMS-10797.Justification for Collecting Social Security Numbers_508.pdf CMS-10797.Justification for Collecting Social Security Numbers_508 IC Document
CMS-10797.Justification for Collecting Social Security Numbers_508.pdf CMS-10797.Justification for Collecting Social Security Numbers_508 IC Document

Information Collection (IC) Details

IC Title:	Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 407.23 42 CFR 406.27

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10797	CMS 10797 Application for Part A and Part B Special Enrollment Period Exceptional Circumstances_508	CMS 10797 Application for Part A and Part B Special Enrollment Period Exceptional Circumstances_508.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 31,499	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	31,499	31,499
Annual IC Time Burden (Hours)	7,875	7,875
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
CMS-10797.Justification for Collecting Social Security Numbers_508	CMS-10797.Justification for Collecting Social Security Numbers_508.pdf	07/05/2022

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.