CMS-10718 Enrollment Form

OMB No. 0938-1378
Expires:7/31/2024

Exhibit 1: MODEL INDIVIDUAL ENROLLMENT REQUEST FORM TO ENROLL IN
A MEDICARE ADVANTAGE PLAN (PART C) OR MEDICARE PRESCRIPTION
DRUG PLAN (PART D)

Who can use this form?

People with Medicare who want to join a Medicare
Advantage Plan or Medicare Prescription Drug Plan
To join a plan, you must:
• Be a United States citizen or be lawfully
present in the U.S.
• Live in the plan’s service area
Important: To join a Medicare Advantage Plan,
you must also have both:
• Medicare Part A (Hospital Insurance)
• Medicare Part B (Medical Insurance)
Important: To join a Medicare Prescription Drug
Plan, you must also have either, or both:
• Medicare Part A (Hospital Insurance)
• Medicare Part B (Medical Insurance)

When do I use this form?

You can join a plan:
• Between October 15–December 7 each year (for
coverage starting January1)
• Within 3 months of first getting Medicare
• In certain situations where you’re allowed to
join or switch plans
Visit Medicare.gov to learn more about when you
can sign up for a plan.

What do I need to complete this form?
•
•

Your Medicare Number (the number on your
red, white, and blue Medicare card)
Your permanent address and phone number

Note: You must complete all items in Section 1.
The items in Section 2 are optional — you can’t be
denied coverage because you don’t fill them out.

Reminders:
•
•

If you want to join a plan during fall open
enrollment (October 15–December 7), the plan
must get your completed form by December 7.
Your plan will send you a bill for the plan’s
premium. You can choose to sign up to have
your premium payments deducted from your
bank account or your monthly Social Security
(or Railroad Retirement Board) benefit.

What happens next?

Send your completed and signed form to:

Once they process your request to join, they’ll
contact you.

How do I get help with this form?

Call at . TTY users
can call < phone number >.
Or, call Medicare at 1-800-MEDICARE
(1-800-633-4227). TTY users can call
1-877-486-2048.
En español: Llame a al o a Medicare gratis al
1-800-633-4227 y oprima el 8 para asistencia en
español y un representante estará disponible para
asistirle.

Individuals experiencing homelessness
•

If you want to join a plan but have no permanent
residence, a Post Office Box, an address of a
shelter or clinic, or the address where you
receive mail (e.g., social security checks) may
be considered your permanent residence
address.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1378. The time required to complete this information is estimated to average 20 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy
of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.
IMPORTANT
Do not send this form or any items with your personal information (such as claims, payments, medical records, etc.) to the PRA Reports Clearance Office. Any items we
get that aren’t about how to improve this form or its collection burden (outlined in OMB 0938-1378) will be destroyed. It will not be kept, reviewed, or forwarded to the
plan. See “What happens next?” on this page to send your completed form to the plan.

Section 1 – All fields on this page are required (unless marked optional)

Select the plan you want to join:
Product ABC – $XX per month
Product XYZ – $XX per month
FIRST name:
LAST name:
[Optional: Middle Initial]:
Birth date: (MM/DD/YYYY)
Sex:
Phone number:
(__ __/__ __/__ __ __ __)
Male
Female (
)
Permanent Residence street address (Don’t enter a PO Box. Note: For individuals experiencing homelessness, a
PO Box may be considered your permanent residence address.):
City:
[Optional: County]:
State:
ZIP Code:

Mailing address, if different from your permanent address (PO Box allowed):
Street address:
City:
State:
ZIP Code:
Your Medicare information:
Medicare Number:
____-___-____
Answer these important questions:
[MA-PD / PDPs insert:
Will you have other prescription drug coverage (like VA, TRICARE) in addition to < Plan>?
Yes
No
Name of other coverage:
Member number for this coverage:
Group number for this coverage
___________________________
____________________________
________________________]
[Special Needs Plans] insert question(s) regarding the required special needs criteria]
IMPORTANT: Read and sign below:
• [MA plans insert: I must keep both Hospital (Part A) and Medical (Part B) to stay in .]
• [Part D plans insert: I must keep Hospital (Part A) or Medical (Part B) to stay in .]
• By joining this Medicare Advantage [or Medicare Prescription Drug] Plan, I acknowledge that
will share my information with Medicare, who may use it to track my enrollment, to make payments, and for
other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act
Statement below). Your response to this form is voluntary. However, failure to respond may affect
enrollment in the plan.
• I understand that I can be enrolled in only one MA or Part D plan at a time – and that enrollment in this plan
will automatically end my enrollment in another MA or Part D plan (exceptions apply for MA PFFS, MA
MSA plans).
• [MA plans insert: I understand that when my coverage begins, I must get all of my medical
and prescription drug benefits from . Benefits and services provided by and
contained in my “Evidence of Coverage” document (also known as a member contract or
subscriber agreement) will be covered. Neither Medicare nor will pay for benefits or services
that are not covered.]
• The information on this enrollment form is correct to the best of my knowledge. I understand that if I
intentionally provide false information on this form, I will be disenrolled from the plan.
• I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this
application means that I have read and understand the contents of this application. If signed by an authorized
representative (as described above), this signature certifies that:
1) This person is authorized under State law to complete this enrollment, and
2) Documentation of this authority is available upon request by Medicare.
Signature:
Today’s date:
If you’re the authorized representative, sign above and fill out these fields:
Name:

Address:

Phone number:

Relationship to enrollee:

Section 2 – All fields in this section are optional

Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.
Are you Hispanic, Latino/a, or Spanish origin? Select all that apply.
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino/a, or Spanish origin
I choose not to answer.
What’s your race? Select all that apply.
American Indian or Alaska Native
Asian:
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian

Black or African American
Native Hawaiian and Pacific Islander:
Guamanian or Chamorro
Native Hawaiian
Samoan
Other Pacific Islander
White
I choose not to answer.

What was your sex assigned at birth? You can find this on an original birth certificate or similar document.
Select one.
Female
I don’t know
Male
I choose not to answer
What is your gender? Select one.
Woman
Man
Non-binary

I use a different term: _______________
I choose not to answer

Which of the following best represents how you think of yourself? Select one.
Lesbian or gay
I use a different term: _______________
Straight, that is, not gay or lesbian
I don’t know
Bisexual
I choose not to answer
Select one if you want us to send you information in a language other than English.
[ Plans insert the languages required in your service area.]
Select one if you want us to send you information in an accessible format.
Braille
Large print
Audio CD
Data CD
Please contact at if you need information in an accessible format other than
what’s listed above. Our office hours are . TTY users can call
Do you work?

Yes

No

Does your spouse work?

List your Primary Care Physician (PCP), clinic, or health center:

Yes

No

I want to get the following materials via email. Select one or more.
[Plans may list those types or categories of materials that are available for electronic delivery]
E-mail address:

Paying your plan premiums

[Plans with premiums insert: You can pay your monthly plan premium [MA-PD plans with premiums insert:
(including any late enrollment penalty that you currently have or may owe)] by mail each month . You can also choose to pay your premium by having it automatically taken out of
your Social Security or Railroad Retirement Board (RRB) benefit each month.]
[MA-PD and PDPs with premiums insert: If you have to pay a Part D-Income Related Monthly Adjustment
Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium. DON’T pay
[insert appropriate plan and/or organization name] the Part D-IRMAA.]

For individuals helping enrollee with completing this form only

Complete this section if you’re an individual (i.e. agents, brokers, SHIP counselors, family members, or other
third parties) helping an enrollee fill out this form.
Name: ______________
Signature: ___________

Relationship to enrollee: ____________
National Producer Number (Agents/Brokers only): ____________

[optional space for other administrative information needed by plan]

PRIVACY ACT STATEMENT

The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage
(MA) Plans, improve care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50 and
422.60 authorize the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the
System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary.
However, failure to respond may affect enrollment in the plan.