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⚠️ Notice: This information collection may be referencing outdated material.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
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

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	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 %

	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

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.