View Information Collection (IC)

View Information Collection (IC)

View Information Collection (IC)

IC Title:	Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)	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 407.23 42 CFR 406.27

Information Collection Instruments:

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

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 34,612	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 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

Documents for IC

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.