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pdfRevisions to Form CMS 10797 (OMB 0938-1426) Application for Medicare Part A and Part B Special Enrollment Period
(Exceptional Circumstances)
The form was updated to add the optional collection of email addresses. In response to SSA technician’s feedback, the form now
includes a question that allows the applicant to select a Medicare start date. CMS’ Office of Communications provided feedback on
the form design and the layout of the questions. The form was redesigned to give the applicant’s a more user-friendly experience. No
additional changes were made, and the burden was not impacted by the changes.
Changes
Updated Form
Original Form
Reason for Change
Title: Application for
Medicare Part A and
Part B Special
Enrollment Period
(Exceptional
Circumstances)
Instructions page
Title: Application for
Medicare Part A and
Part B Special
Enrollment Period
(Exceptional
Conditions)
Instructions page
Updated to plain language.
Burden
Effect
N/A
Updated to plain language.
N/A
Basic Information
• New, optional,
email address
collection
Tell us about yourself
•
SEP (Exceptional
Conditions)
•
Enrollment in Part B
Signature
Enrollment in SEP
(Exceptional
Conditions)
Attachment 1
Application Signature
Attachment 1
•
•
Updated formatting to
match Medicare brand &
style
Updated language to
align with Medicare.gov
program info
Linked to Medicare.gov
for program details so
info is current &
comprehensive
Added SHIPs resource
language to the “Get
help” section
N/A
•
•
•
Removed field numbers
unless used for
navigation (i.e. “go to
item 4”)
Standardized field labels
across forms
Standardized the
“witness” section across
forms
File Type | application/pdf |
File Title | Crosswalk of Changes CMS 10797 |
Author | Carla Patterson |
File Modified | 2024-10-21 |
File Created | 2024-10-21 |