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

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Form and Instruction
Form and Instruction
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Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 407.23 42 CFR 406.27

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.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

Health Health Care Services

 

34,612 0
   
Individuals or Households
 
   80 %

  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

Title Document Date Uploaded
Track Change: Application CMS Form 10797 Current form redlined.pdf 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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