Information Collection

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

IC 254496 under ICR 202207-0938-005 · OMB 0938-1426.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.