CMS-10797- An Important Form for Many to Know About

Stephanie Frisch is the owner of Insurance 101 and is an independent insurance broker dedicated to helping others make “educated decisions” about their insurance choices when it comes to Medicare. For answers to your questions, or no-fee consultation, call 949-292-4958.

According to, the purpose of this form is if, due to an exceptional condition, you didn’t sign up for Medicare Premium Part A (some people have to pay for it if they didn’t pay for 40 quarters into the Medicare tax) or Part B during your Initial Enrollment Period (IEP), General Enrollment Period (GEP), or a Special Enrollment Period (SEP) you were previously eligible for, but didn’t take into action due to some specific circumstances. You can sign up without a late enrollment penalty during a SEP for Exceptional Conditions.

If you think you may be eligible for a SEP for Exceptional Conditions, contact Social Security at 1-800-772-1213. You can also contact your local Social Security office. To find an office near you go to

Some examples of a Special Enrollment Period for Exceptional Conditions (all beginning on or after 1/1/23 would be):

SEP for Individuals Impacted by an Emergency or National Disaster.

SEP for Group Health Plan or Employer Misrepresentation. ( I see people impacted by this one a lot).

SEP for Termination of Medi-Cal Eligibility (you have 6 months after receiving notice of termination of your benefits)

SEP for other Exceptional Conditions (Select this SEP if you have a different exceptional condition that occurred and is not listed above).

This form is not difficult to fill out if you read it line by line and provide supporting documentation or sign a written attestation under penalty of perjury.

If the misrepresentation leading to your SEP Exceptional Condition was caused by your employer, group health plan, agent or broker, there will be an additional attestation to fill out for that.

You can get the most up-to-date form CMS-10797 by going to or just to your favorite web browser search tool.

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November 2023