Information Collection

Election Process (MA organization)

IC 240722 under ICR 202205-0938-003 · OMB 0938-1378.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1378 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10718 Election Process (MA organization) Form and Instruction
CMS-10718 Enrollment Form CMS 10718_CY 2023 Model MA PDP Indiv Enrollment Request Form.pdf Form and Instruction
CMS-10718 Enrollment Form Model Indiv Enrollment Request Form OMB No. 0938-1378.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Election Process (MA organization)	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 422.50 42 CFR 422.60

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10718	Enrollment Form	Model Indiv Enrollment Request Form OMB No. 0938-1378.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Medicare Advantage Prescription Drug (MARx) System	FR Citation: 83 FR 6591

Number of Respondents: 700	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,021,588	1,421,986	8,599,602
Annual IC Time Burden (Hours)	2,160,124	545,978	1,614,146
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.