Information Collection

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

IC 254496 under ICR 202210-0938-009 · OMB 0938-1426.

⚠️ Notice: This information collection may be referencing outdated material.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

2025-03-28 - Reinstatement with change of a previously approved collection

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
HI 00805.382 _ Special Enrollment Periods for Exceptional Conditions_DRAFT.docx	Instruction
HI 00805.383_SEP for Individuals Impacted by an Emergency or Disaster Draft.docx	Instruction
HI 00805.384_SEP for Private Group Health Plan or Employer Error Draft.docx	Instruction
HI 00805.385_SEP following loss of Medicaid Draft.docx	Instruction
HI 00805.386_SEP for Formerly Incarcerated Individuals_DRAFT.docx	Instruction
HI 00805.387_SEP for Other Exceptional Conditions Draft.docx	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 Medicare Part A and Part B Special enrollment period v3.pdf	Form and Instruction
CMS-10797 iClaim iClaim SEP Screens 10052022.pdf	Form and Instruction
CMS-10797 iClaim iClaim SEP Screens 10052022.pdf	Form and Instruction
CMS-10797 SEP UI CAA - SEP UI Mock-ups - 221024.pdf	Form and Instruction
CMS-10797 SEP UI CAA - SEP UI Mock-ups - 221024.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
Crosswalk of Changes CMS 10797.pdf Crosswalk: Application	IC Document
Crosswalk of Changes CMS 10797 v2.docx Crosswalk: Application	IC Document
CMS 10797 Application for Part A and Part B Special Enrollment Period Exceptional Circumstances_508 Combined Track Changes.docx Track Change: Application	IC Document

Information Collection (IC) Details

View Information Collection (IC)

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: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 406.27 42 CFR 407.23

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	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	Medicare Part A and Part B Special enrollment period v3.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-10797	iClaim	iClaim SEP Screens 10052022.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10797	SEP UI	CAA - SEP UI Mock-ups - 221024.pdf	Yes	Yes	Fillable Fileable
Instruction			HI 00805.382 _ Special Enrollment Periods for Exceptional Conditions_DRAFT.docx	Yes	No	Printable Only
Instruction			HI 00805.383_SEP for Individuals Impacted by an Emergency or Disaster Draft.docx	Yes	No	Printable Only
Instruction			HI 00805.384_SEP for Private Group Health Plan or Employer Error Draft.docx	Yes	No	Printable Only
Instruction			HI 00805.385_SEP following loss of Medicaid Draft.docx	Yes	No	Printable Only
Instruction			HI 00805.386_SEP for Formerly Incarcerated Individuals_DRAFT.docx	Yes	No	Printable Only
Instruction			HI 00805.387_SEP for Other Exceptional Conditions Draft.docx	Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 31,465

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 80 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	31,465	31,465
Annual IC Time Burden (Hours)	18,094	18,094
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
Crosswalk: Application	Crosswalk of Changes CMS 10797 v2.docx	11/08/2022
Track Change: Application	CMS 10797 Application for Part A and Part B Special Enrollment Period Exceptional Circumstances_508 Combined Track Changes.docx	11/07/2022

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