Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)

Model Medicare Advantage and Medicare Prescription Drug Plan Individual Enrollment Request Form (CMS-10718)

Documents and Forms

Document Name Document Type
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Beneficiaries) Form and Instruction
CMS-10718 Enrollment Form CY 2025- Model MA PDP Indiv Enrollment Request Form.docx Form and Instruction
CMS-10718 Enrollment Form CY 2025- Model MA PDP Indiv Enrollment Request Form.docx Form and Instruction
CMS-10718 Enrollment Form (Spanish) Spanish_CY 2025 - Model MA PDP Indiv Enrollment Request Form.pdf Form and Instruction
CMS-10718 Enrollment Form (Spanish) Spanish_CY 2025 - Model MA PDP Indiv Enrollment Request Form.pdf Form and Instruction
CMS-10718 Enrollment Form (Korean) Korean_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf Form and Instruction
CMS-10718 Enrollment Form (Korean) Korean_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf Form and Instruction
CMS-10718 Enrollment Form (Traditional Chinese) TChinese_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf Form and Instruction
CMS-10718 Enrollment Form (Traditional Chinese) TChinese_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf Form and Instruction
CMS-10718 Enrollment Form (Vietnamese) Vietnamese_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf Form and Instruction
CMS-10718 Enrollment Form (Vietnamese) Vietnamese_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Eligibility and Enrollment Eligibility and enrollment (Beneficiaries)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 423.32

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10718	Enrollment Form	CY 2025- Model MA PDP Indiv Enrollment Request Form.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10718	Enrollment Form (Spanish)	Spanish_CY 2025 - Model MA PDP Indiv Enrollment Request Form.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10718	Enrollment Form (Korean)	Korean_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10718	Enrollment Form (Traditional Chinese)	TChinese_CY 2025- Model MA PDP Indiv Enrollment Request Form.pdf	Yes	Yes	Fillable Printable
Form and Instruction	CMS-10718	Enrollment Form (Vietnamese)	Vietnamese_CY 2025- Model MA PDP Indiv Enrollment Request Form.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: 8,118,410	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	8,118,410	8,118,410
Annual IC Time Burden (Hours)	2,703,431	2,703,431
Annual IC Cost Burden (Dollars)	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.