View Information Collection (IC)
View Information Collection (IC)

View Information Collection (IC)

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 Yes No Fillable Fileable
Form and Instruction CMS-10797 Yes Yes Fillable Fileable
Form and Instruction CMS-10797 Yes Yes Fillable Fileable
Instruction Yes No Printable Only
Instruction Yes No Printable Only
Instruction Yes No Printable Only
Instruction Yes No Printable Only
Instruction Yes No Printable Only
Instruction Yes No Printable Only

Health Health Care Services

 

34,612 0
   
Individuals or Households
 
   80 %

  Requested 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 0 0 34,612
Annual IC Time Burden (Hours) 19,901 0 0 0 0 19,901
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
REDLINE: Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) 08/10/2026
CROSSWALK: Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) 08/10/2026
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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