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Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)
Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) (CMS-10797)
OMB: 0938-1426
IC ID: 254496
OMB.report
HHS/CMS
OMB 0938-1426
ICR 202501-0938-010
IC 254496
( )
Documents and Forms
Document Name
Document Type
Form CMS-10797
Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)
Form and Instruction
HI 00805.382 _ Special Enrollment Periods for Exceptional Conditions_DRAFT.docx
Instruction
HI 00805.383_SEP for Individuals Impacted by an Emergency or Disaster Draft.docx
Instruction
HI 00805.384_SEP for Private Group Health Plan or Employer Error Draft.docx
Instruction
HI 00805.385_SEP following loss of Medicaid Draft.docx
Instruction
HI 00805.386_SEP for Formerly Incarcerated Individuals_DRAFT.docx
Instruction
HI 00805.387_SEP for Other Exceptional Conditions Draft.docx
Instruction
CMS-10797 Application for Medicare Part A and Part B Special Enrol
CMS-10797 Redesigned_.docx
Form and Instruction
CMS-10797 iClaim
iClaim SEP Screens 10052022.pdf
Form and Instruction
CMS-10797 SEP UI
CAA - SEP UI Mock-ups - 221024.pdf
Form and Instruction
CMS Form 10797 Current form redlined.pdf
Track Change: Application
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)
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 406.27
42 CFR 407.23
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-10797
Application for Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)
CMS-10797 Redesigned_.docx
Yes
No
Fillable Fileable
Form and Instruction
CMS-10797
iClaim
iClaim SEP Screens 10052022.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10797
SEP UI
CAA - SEP UI Mock-ups - 221024.pdf
Yes
Yes
Fillable Fileable
Instruction
HI 00805.382 _ Special Enrollment Periods for Exceptional Conditions_DRAFT.docx
Yes
No
Printable Only
Instruction
HI 00805.383_SEP for Individuals Impacted by an Emergency or Disaster Draft.docx
Yes
No
Printable Only
Instruction
HI 00805.384_SEP for Private Group Health Plan or Employer Error Draft.docx
Yes
No
Printable Only
Instruction
HI 00805.385_SEP following loss of Medicaid Draft.docx
Yes
No
Printable Only
Instruction
HI 00805.386_SEP for Formerly Incarcerated Individuals_DRAFT.docx
Yes
No
Printable Only
Instruction
HI 00805.387_SEP for Other Exceptional Conditions Draft.docx
Yes
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
34,612
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
80 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
34,612
0
0
3,147
31,465
0
Annual IC Time Burden (Hours)
19,901
0
0
1,807
18,094
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Track Change: Application
CMS Form 10797 Current form redlined.pdf
03/21/2025
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.