Information Collection

Appointment of Representative and Supporting Regulations in 42 CFR 405.910

IC 8804 under ICR 200704-0938-005 · OMB 0938-0950.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0950 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-1696 English Appointment of Representative and Supporting Regulations in 42 CFR 405.910 Form and Instruction
CMS-1696 English APPOINTMENT??OF??REPRESENTATIVE cms1696.pdf Form and Instruction
CMS--1696 SP NOMBRAMIENTO DE REPRESENTANTE 1696-span.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Appointment of Representative and Supporting Regulations in 42 CFR 405.910	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1696 English	APPOINTMENT??OF??REPRESENTATIVE	cms1696.pdf		Yes	Yes	Paper Only
Form and Instruction	CMS--1696 SP	NOMBRAMIENTO DE REPRESENTANTE	1696-span.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 5,455,461	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	5,455,461	5,455,461
Annual IC Time Burden (Hours)	6,819	6,819
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.