Information Collection

Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)

IC 240724 under ICR 202505-0938-017 · OMB 0938-1378.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1378 can be found here:

2025-12-16 - Extension without change of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	Form and Instruction
Form CMS-10718 Enrollment Form Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	Form and Instruction
Form CMS-10718 Enrollment Form (Spanish) Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	Form and Instruction
Form CMS-10718 Enrollment Form (Korean) Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	Form and Instruction
Form CMS-10718 Enrollment Form (Traditional Chinese) Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	Form and Instruction
Form CMS-10718 Enrollment Form (Vietnamese) Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)	Form and Instruction
CMS-10718 Enrollment Form CY 2025 revised - Model MA PDP Indiv Enrollment Request Form (clean).docx	Form and Instruction
CMS-10718 Enrollment Form CY 2025 revised - Model MA PDP Indiv Enrollment Request Form (clean).docx	Form and Instruction
CMS-10718 Enrollment Form (Spanish) Spanish_CY 2025 - Model MA PDP Indiv Enrollment Request Form_508.pdf	Form and Instruction
CMS-10718 Enrollment Form (Spanish) Spanish_CY 2025 - Model MA PDP Indiv Enrollment Request Form_508.pdf	Form and Instruction
CMS-10718 Enrollment Form (Korean) Korean_CY 2025- Model MA PDP Indiv Enrollment Request Form_508.pdf	Form and Instruction
CMS-10718 Enrollment Form (Korean) Korean_CY 2025- Model MA PDP Indiv Enrollment Request Form_508.pdf	Form and Instruction
CMS-10718 Enrollment Form (Traditional Chinese) TChinese_CY 2025- Model MA PDP Indiv Enrollment Request Form_508.pdf	Form and Instruction
CMS-10718 Enrollment Form (Traditional Chinese) TChinese_CY 2025- Model MA PDP Indiv Enrollment Request Form_508.pdf	Form and Instruction
CMS-10718 Enrollment Form (Vietnamese) Vietnamese_CY 2025- Model MA PDP Indiv Enrollment Request Form_508.pdf	Form and Instruction
CMS-10718 Enrollment Form (Vietnamese) Vietnamese_CY 2025- Model MA PDP Indiv Enrollment Request Form_508.pdf	Form and Instruction
CY 2025 revised - Model MA PDP Indiv Enrollment Request Form.pdf Track Change - Model MA PDP Indiv Enrollment Request Form	IC Document
CY 2025 revised - Model MA PDP Indiv Enrollment Request Form.pdf Track Change - Model MA PDP Indiv Enrollment Request Form	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.32(c)

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10718	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10718	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10718	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10718	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10718	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Advantage Prescription Drug (MARx) System

FR Citation: 83 FR 6591

Number of Respondents: 63

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	8,118,410	8,118,410
Annual IC Time Burden (Hours)	1,623,682	1,623,682
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Track Change - Model MA PDP Indiv Enrollment Request Form		04/04/2025

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

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