OMB control number
Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) (CMS-10797)
OMB 0938-1426 · HHS/CMS.
OMB 0938-1426
The CMS-10797 provides the necessary information to determine eligibility and to process the beneficiary’s request for enrollment in premium Part A or Part B due to an exceptional circumstance. This form is only used for enrollment by beneficiaries who did not enroll during another enrollment period due to an exceptional circumstance.
The latest form for Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) (CMS-10797) expires 2028-07-31 and can be found here.
Latest Forms, Documents, and Supporting Material
Document Name |
|---|
Form and Instruction |
Supporting Statement A |
Supplementary Document |
Form CMS-10797 Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)
CMS-10797 - Supporting Statement A.docx
Crosswalk of Changes CMS 10797_508.pdf
Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) All Historical Document Collections
| Reinstatement with change of a previously approved collection | 2025-03-28 | ||
|
Approved with change |
New collection (Request for a new OMB Control Number) | 2022-10-28 | |
|
Comment filed on proposed rule |
New collection (Request for a new OMB Control Number) | 2022-07-05 |