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Federal forms, ICRs, and supporting documents

Information Collection

Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)

IC 254496 under ICR 202501-0938-010 · OMB 0938-1426.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form CMS-10797
Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)		 Form and Instruction
Form CMS-10797
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)		 Form and Instruction
Form CMS-10797
iClaim Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)		 Form and Instruction
Form CMS-10797
SEP UI 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 00805.382 _ 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 00805.383_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 00805.384_SEP for Private Group Health Plan or Employer Error Draft.docx Instruction
HI 00805.385_SEP following loss of Medicaid Draft.docx Instruction
HI 00805.385_SEP following loss of Medicaid Draft.docx Instruction
HI 00805.386_SEP for Formerly Incarcerated Individuals_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
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 Application for Medicare Part A and Part B Special Enrol
CMS-10797.docx 		Form and Instruction
CMS-10797 iClaim
iClaim SEP Screens 10052022.pdf 		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-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
CMS Form 10797 Current form redlined.pdf
Track Change: Application		IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

Information Collection Instruments:
table that charts list of instruments
Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10797 Yes No Fillable Fileable
Form and Instruction CMS-10797 Yes Yes Fillable Fileable
Form and Instruction CMS-10797 Yes Yes Fillable Fileable
Instruction Yes No Printable Only
Instruction Yes No Printable Only
Instruction Yes No Printable Only
Instruction Yes No Printable Only
Instruction Yes No Printable Only
Instruction Yes No Printable Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved 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
table that charts IC Documents
Title Document Date Uploaded
Track Change: Application 06/02/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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