CMS10797

Use this form to enroll in Medicare Part A (Hospital Insurance) or Part B (Medical Insurance) during a Special Enrollment Period due to exceptional circumstances such as natural disasters, loss of Medicaid coverage, or release from incarceration. You must provide written proof of circumstances beyond your control that prevented enrollment during your Initial Enrollment Period. Submit your completed and signed form by mail, fax, or by visiting your local Social Security office in person. Contact Social Security at 1-800-772-1213 (TTY 1-800-325-0778) with questions.