OMB control number
Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form (CMS-10718)
OMB 0938-1378 · HHS/CMS.
OMB 0938-1378
As established by Section 1851 of the Act, and implementing regulations at §§ 422.50 and 422.60, an MA-eligible individual who meets the eligibility requirements for enrollment into an MA plan may enroll during the enrollment periods specified in §422.62, by completing an enrollment form with the MA organization or enrolling through other mechanisms that the Centers for Medicare & Medicaid Services (CMS) determines are appropriate. In addition, the authority for requiring this data collection for PDP enrollment is section 1860D-1 of the Act, and implementing regulations at §§ 423.30 and 423.32, a Part D-eligible individual who wishes to enroll in a Medicare Prescription Drug Plan (PDP) may enroll during the enrollment periods specified in §423.38, by completing an enrollment form with the PDP, or enrolling through other mechanisms CMS determines are appropriate.
The latest form for Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form (CMS-10718) expires 2029-02-28 and is listed under ICR 202512-0938-014.
Latest Forms, Documents, and Supporting Material
Form CMS-10718 Enrollment Form
National Health Law Program.pdf 
Required Notice for Reinstatements Based on Beneficiary Cancellation of New Enrollment ((§§ 422.60 and 423.32))All Historical Document Collections
OMB Details
Election Process (Beneficiaries) (422.60)
Federal Enterprise Architecture: Health - Health Care Services
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form CMS-10718 | Enrollment Form | Fillable Printable | Form and instruction |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.