Information Collection Request
Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) (CMS-10797)
ICR 202210-0938-009 · OMB 0938-1426 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1426 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CMS-10797 Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) |
Form and Instruction | Modified | Repair queued |
 CMS-10797 - Supporting Statement A (CMS-4199-F version 11.1).docx |
Supporting Statement A | Uploaded 2022-10-28 | Repair queued |
 Response to Comments OMB 0938 1426.pdf |
Supplementary Document | Uploaded 2022-10-27 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 254496 |  Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) |
Form and Instruction | Modified | |
| 254496 | Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-1426 |
| Type of Information Collection | New collection (Request for a new OMB Control Number) |
| Previous ICR Reference No | 202207-0938-005 |
| Agency Tracking No | CM-CPC |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |