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)

OMB: 0938-1426

IC ID: 254496

Documents and Forms
Document Name
Document Type
Form and Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
IC Document
IC Document
IC Document
IC Document
IC Document
Information Collection (IC) Details

View Information Collection (IC)

Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 406.27 42 CFR 407.23

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 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

Health Health Care Services

 

31,465 0
   
Individuals or Households
 
   80 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 31,465 31,465 0 0 0 0
Annual IC Time Burden (Hours) 18,094 18,094 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.
© 2024 OMB.report | Privacy Policy