Eligibility and Enrollment Eligibility and enrollment (Part D sponsor)

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

OMB: 0938-1378

IC ID: 240724

Documents and Forms

Document Name Document Type
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Part D sponsor) Form and Instruction
Form CMS-10718 Eligibility and Enrollment Eligibility and enrollment (Part D sponsor) Form and Instruction
CMS-10718 Enrollment Form CY 2025 revised - Model MA PDP Indiv Enrollment Request Form (clean).docx Form and Instruction
CMS-10718 Enrollment Form CY 2025 revised - Model MA PDP Indiv Enrollment Request Form (clean).docx Form and Instruction
CMS-10718 Enrollment Form (Spanish) Spanish_CY 2025 - Model MA PDP Indiv Enrollment Request Form_508.pdf Form and Instruction
CMS-10718 Enrollment Form (Spanish) Spanish_CY 2025 - Model MA PDP Indiv Enrollment Request Form_508.pdf Form and Instruction
CMS-10718 Enrollment Form (Korean) Korean_CY 2025- Model MA PDP Indiv Enrollment Request Form_508.pdf Form and Instruction
CMS-10718 Enrollment Form (Korean) Korean_CY 2025- Model MA PDP Indiv Enrollment Request Form_508.pdf Form and Instruction
CMS-10718 Enrollment Form (Traditional Chinese) TChinese_CY 2025- Model MA PDP Indiv Enrollment Request Form_508.pdf Form and Instruction
CMS-10718 Enrollment Form (Traditional Chinese) TChinese_CY 2025- Model MA PDP Indiv Enrollment Request Form_508.pdf Form and Instruction
CMS-10718 Enrollment Form (Vietnamese) Vietnamese_CY 2025- Model MA PDP Indiv Enrollment Request Form_508.pdf Form and Instruction
CMS-10718 Enrollment Form (Vietnamese) Vietnamese_CY 2025- Model MA PDP Indiv Enrollment Request Form_508.pdf Form and Instruction
CY 2025 revised - Model MA PDP Indiv Enrollment Request Form.pdf Track Change - Model MA PDP Indiv Enrollment Request Form IC Document
CY 2025 revised - Model MA PDP Indiv Enrollment Request Form.pdf Track Change - Model MA PDP Indiv Enrollment Request Form IC Document