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OMB Control No: 0938-1426	ICR Reference No: 202608-0938-010
Status: Received in OIRA	Previous ICR Reference No: 202501-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) (CMS-10797)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 08/10/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	07/31/2028
Responses	34,612	34,612
Time Burden (Hours)	19,901	19,901
Cost Burden (Dollars)	0	0

Annual Cost to Federal Government: $299,740

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

Agency Contact: Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov

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