Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)

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

OMB: 0938-1378

IC ID: 240723

Documents and Forms

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 (Spanish) CY 2025- Model MA PDP Indiv Enrollment Request Form_Spanish.pdf Form and Instruction