Official Federal Forms
Centers For Medicare And Medicaid Services
Last updated: 5/17/2023
Application For Medicare Part A And Part B Special Enrollment {CMS-10797}
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Description
CMS-10797 - APPLICATION FOR MEDICARE PART A AND PART B – SPECIAL ENROLLMENT PERIOD (EXCEPTIONAL CONDITIONS). The purpose of this form is if, due to an exceptional condition, you didn’t sign up for Medicare Premium Part A or Part B during your Initial Enrollment Period (IEP), General Enrollment Period (GEP), or a Special Enrollment Period (SEP) you were previously eligible for, you can sign up without a late enrollment penalty during a SEP for Exceptional Conditions. If you think that you may be eligible for a SEP for Exceptional Conditions, please contact Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. NOTE: Your IEP lasts for 7 months. It begins 3 months before your 65th birthday (or 25th month of disability) and ends 3 months after you reach 65 (or 3 months after the 25th month of disability). The GEP is from January 1 – March 31 each year. The most common SEPs apply to the working aged, disabled, and international volunteers. www.FormsWorkflow.com
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