Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID)

Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID) (CMS-10798)

Documents and Forms

Document Name Document Type
Form CMS-10798 Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID) Form and Instruction
CMS-10798 Application for Enrollment in Part B Immunosuppressive D CMS-10798 Redesigned Form.docx Form and Instruction
CMS-10798.Justification for Collecting Social Security Numbers_508.pdf Justification for Collecting SSNs IC Document
CMS-10798-Current Forml DEEP Redline.pdf Track Change - Application IC Document

Information Collection (IC) Details

IC Title:	Application for Enrollment in Part B Immunosuppressive Drug Coverage (Part B-ID)	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 407.1(a)(6)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10798	Application for Enrollment in Part B Immunosuppressive Drug Coverage	CMS-10798 Redesigned Form.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Master Beneficiary Record	FR Citation: 71 FR 1826

Number of Respondents: 1,019	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,019	252	767
Annual IC Time Burden (Hours)	173	45	128
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Justification for Collecting SSNs	CMS-10798.Justification for Collecting Social Security Numbers_508.pdf	10/21/2022
Track Change - Application	CMS-10798-Current Forml DEEP Redline.pdf	05/29/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.