Application For Enrollment In Part B Immunosuppressive Drug Coverage {CMS-10798}

CMS-10798 - APPLICATION FOR ENROLLMENT IN PART B IMMUNOSUPPRESSIVE DRUG COVERAGE. Use this form if you or your child/dependent had a kidney transplant and have lost or will be losing their Medicare coverage that was based on ESRD 36 months after their kidney transplant. NOTE: If you or your child/dependent have other health coverage, or you or your child/dependent have Medicaid or State Children's Health Insurance Program (CHIP) that covers immunosuppressive drugs, do not complete this form. You should use this form: • If you or your child/dependent have lost or will be losing Medicare coverage that was based on ESRD 36 months after a kidney transplant, and you/they want to enroll in the Part B-ID benefit for coverage of immunosuppressive drugs. • If you or your child/dependent are not enrolled in any other health insurance coverage (except Medicaid or CHIP that does not cover immunosuppressive drugs). • If you or your child/dependent do not expect to enroll in any other health insurance coverage (except Medicaid or CHIP that does not cover immunosuppressive drugs). • You do not currently have Medicare based on being age 65 or older or based on having a disability. www.FormsWorkflow.com