Page 1: Personal information
Social Security Number or Medicare Number, name, name at birth if different, sex, date of birth, state or country of birth, home and mailing address, phone and email, and a yes or no question on signing up for Part B.
CMS-10797
Application For Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances)
- Agency
- CMS
- Revision
- 07/2025
- Fillable fields
- 72
- Pages
- 6
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-10797: Part A and Part B Special Enrollment Period (Exceptional Circumstances)
Form CMS-10797 is the Application for Medicare Part A and Part B Special Enrollment Period (Exceptional Circumstances) from the Centers for Medicare & Medicaid Services, part of the U.S. Department of Health and Human Services. The form says it is used to sign up for Medicare Part A (Hospital Insurance) or Part B (Medical Insurance) during a Special Enrollment Period because of an exceptional situation, such as being impacted by a natural emergency or disaster, losing Medicaid coverage, or being released from jail.
The form says applicants will need to provide written proof that circumstances outside their control prevented them from enrolling during their Initial Enrollment Period or another valid enrollment period. It lists five Special Enrollment Periods to pick from and ends with an Attestation page for explaining the condition in detail.
The form says to mail or fax the completed, signed form to a local Social Security office, and the CMS page adds that it can also be submitted in person there. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-10797
Emergency or disaster dates
Start and end dates (mm/yy) of the declared emergency and an optional description. The form says this period begins at the start of the emergency and ends 6 months after the declared end date.
Misrepresentation evidence
The form asks for documents from the employer or health plan showing the incorrect information, received before the end of a valid enrollment period. Without evidence, it asks for a written statement on the Attestation page.
Lost Medicaid start date
A coverage start choice: Option 1, the first day of the month after enrolling, or Option 2, the first day of the month Medicaid ended, with premiums paid back for each month since. It asks for a state or plan document showing the end date.
Incarceration dates and start date
Dates of incarceration and release (mm/yy) and a coverage start choice: Option 1, the month after enrolling, or Option 2, the month of release (up to 6 months back), with premiums paid back since release.
Signatures and Attestation
A signature and date, with a witness if signed by mark (X). The Attestation (Attachment 1) asks for the dates of the condition, the missed enrollment periods and a detailed explanation, with a box for an added sheet.
Five pages: personal details, the Special Enrollment Period choices, signatures and an Attestation.
How to submit Form CMS-10797
- 1
Fill out page 1
Enter your SSN or Medicare Number, name, birth details, addresses, phone and email, and answer whether you want to sign up for Part B.
- 2
Pick one Special Enrollment Period
Select the Special Enrollment Period that best fits your situation and enter the dates it asks for.
- 3
Choose a coverage start date
For lost Medicaid or release from incarceration, check Option 1 or Option 2. The form says a blank choice means Option 1.
- 4
Attach proof or the Attestation
Attach the documents the chosen period asks for. For misrepresentation without evidence, or other exceptional conditions, complete the Attestation on page 5.
- 5
Sign and date
Sign and date the application. A form signed by mark (X) also needs a witness's name, signature and date.
- 6
Send it to Social Security
Mail or fax the completed, signed form to your local Social Security office. The CMS page adds that it can be submitted in person. Find an office at SSA.gov/locator.
Why fill Form CMS-10797 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes, enrollment periods and help
Where to send it
To your local Social Security office by mail or fax, or in person according to the CMS page. Find an office at SSA.gov/locator. The form says not to send it to the CMS PRA Reports Clearance Office address, which is for comments on the form only.
Initial Enrollment Period
The form says the Initial Enrollment Period lasts 7 months, from 3 months before the month you reach 65 to 3 months after. With Medicare due to disability, it begins 3 months before the 25th month of getting Social Security Disability.
Late enrollment penalty
The form says signing up after the Initial Enrollment Period may bring a late enrollment penalty of 10% for each full 12-month period without Part B while eligible.
Health Savings Accounts
The form says people with a Health Savings Account (HSA) should stop contributing 6 months before applying for Medicare to avoid an IRS penalty, and points to IRS.gov.
Help with the form
Social Security: 1-800-772-1213, TTY 1-800-325-0778, with Spanish service by pressing 2. Free health insurance counseling is available from your State Health Insurance Assistance Program (SHIP) at shiphelp.org.
Time to complete
The form estimates an average of 15 minutes per response, including reviewing the instructions and gathering the information.
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Who uses Form CMS-10797?
The form is for signing up for Part A or Part B during a Special Enrollment Period for an exceptional situation. It lists these situations, each dated on or after January 1, 2023.
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Questions about Form CMS-10797
What is Form CMS-10797 used for?
The form says it is used to sign up for Medicare Part A or Part B during a Special Enrollment Period because of an exceptional situation, such as a natural disaster, losing Medicaid or release from jail.
What proof does Form CMS-10797 ask for?
The form says you'll need written proof that circumstances outside your control prevented you from enrolling. Each Special Enrollment Period names its documents, and the Attestation page is for a written explanation.
Where do I send Form CMS-10797?
The form says to mail or fax the completed, signed form to your local Social Security office. The CMS page adds that it can be submitted in person. Find an office at SSA.gov/locator.
Is there a date limit on the exceptional situations?
Yes. Each Special Enrollment Period on the form says the event (the declared emergency, the misinformation, the loss of Medicaid, the release or the other condition) must be on or after January 1, 2023.
Can I choose when Medicare coverage starts?
For lost Medicaid and release from incarceration, the form offers Option 1 (the month after enrolling) or Option 2 (an earlier month, with premiums paid back). It says a blank choice means Option 1.
What is the Attestation page?
Attachment 1 on page 5 asks for the dates the condition happened, the missed enrollment periods and a detailed explanation, including the names and titles of anyone else involved.
What if none of the listed periods fit?
The form says to contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) to see if there are other available options.