Crosswalk

Revisions 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