Information Collection

Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)

IC 240723 under ICR 202401-0938-002 · OMB 0938-1378.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)	Form and Instruction
CMS-10718 Enrollment Form CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf	Form and Instruction
CMS-10718 Enrollment Form CY 2025- Model MA PDP Indiv Enrollment Request Form.docx	Form and Instruction
CMS-10718 Enrollment Form (Spanish) CY 2025- Model MA PDP Indiv Enrollment Request Form_Spanish.pdf	Form and Instruction
CMS-10718 Enrollment Form (Spanish) Spanish_CY 2025 - Model MA PDP Indiv Enrollment Request Form.pdf	Form and Instruction
CMS-10718 Enrollment Form (Korean) Korean_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf	Form and Instruction
CMS-10718 Enrollment Form (Traditional Chinese) TChinese_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf	Form and Instruction
CMS-10718 Enrollment Form (Vietnamese) Vietnamese_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf	Form and Instruction

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:

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-10718	Enrollment Form	CY 2025- Model MA PDP Indiv Enrollment Request Form.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10718	Enrollment Form (Spanish)	Spanish_CY 2025 - Model MA PDP Indiv Enrollment Request Form.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10718	Enrollment Form (Korean)	Korean_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10718	Enrollment Form (Traditional Chinese)	TChinese_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10718	Enrollment Form (Vietnamese)	Vietnamese_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf	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: 8,118,410

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	8,118,410	2,247,156	5,871,254
Annual IC Time Burden (Hours)	2,703,431	746,346	1,957,085
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.