Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)

Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form (CMS-10718)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1378 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Beneficiaries) Form and Instruction
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Beneficiaries) Form and Instruction
CMS-10718 Enrollment Form CY 2023 Model PDP Indiv Enrollment Request Form 0938-1378.docx Form and Instruction
CMS-10718 Enrollment Form CY 2023 Model PDP Indiv Enrollment Request Form 0938-1378.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)	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 423.32

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10718	Enrollment Form	CY 2023 Model PDP Indiv Enrollment Request Form 0938-1378.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Advantage Prescription Drug (MARx) System	FR Citation: 83 FR 6591

Number of Respondents: 5,871,254	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	5,871,254	5,871,254
Annual IC Time Burden (Hours)	1,957,085	1,957,085
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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