Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Beneficiary)

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES		Form Approved OMB no. 09380950
APPOINTMENT OF REPRESENTATIVE
NAME OF BENEFICIARY PARTY	MEDICARE NUMBER OR NATIONAL PROVIDER IDENTIFIER NUMBER

SECTION I: APPOINTMENT OF REPRESENTATIVE To be completed by the party seeking representation (i.e., the Medicare beneficiary, the provider or the supplier) beneficiary:

I appoint this individual: ___________________________________ to act as my representative in connection with my claim or asserted right under Title XVIII of the Social Security Act (the “Act”) and related provisions of Title XI of the Act. I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my appeal, wholly in my stead. I understand that personal medical information related to my appeal may be disclosed to the representative indicated below.

SIGNATURE OF BENEFICIARY PARTY SEEKING REPRESENTATION	DATE
STREET ADDRESS	PHONE NUMBER (WITH AREA CODE)
CITY	STATE	ZIP

SECTION II: ACCEPTANCE OF APPOINTMENT To be completed by the representative:

I, ________________________________, hereby accept the above appointment. I certify that I have not been disqualified, suspended, or prohibited from practice before the Department of Health and Human Services; that I am not, as a current or former employee of the United States, disqualified from acting as the beneficiary’s party’s representative; and that I recognize that any fee may be subject to review and approval by the Secretary.

I am a / an__________________________________________________________________________________________

(PROFESSIONALSTATUS OR RELATIONSHIP TO THE PARTY, E.G. ATTORNEY, RELATIVE, ETC.) 

SIGNATURE OF REPRESENTATIVE	DATE
STREET ADDRESS	PHONE NUMBER (WITH AREA CODE)
CITY	STATE	ZIP

SECTION III: WAIVER OF FEE FOR REPRESENTATION Instructions: This sectionform must be completed should be filled out if the representative is required to, or chooses to waives theira fee for such representation.

(Note that  providers or suppliers may not charge a fee for representation and thus, all providers or suppliers that are representing a beneficiary and

furnished the items or services  may not charge a fee for representation and at issue must complete this section.) I waive my right to charge and collect a fee for representing __________________________________________________ before the Secretary of the Department of Health and Human Services.

SIGNATURE

DATE

SECTION IV: WAIVER OF PAYMENT FOR ITEMS OR SERVICES AT ISSUE

Instructions: Providers or suppliers serving as a representative for a beneficiary to whom they provided items or services that furnished the items or services at issue must complete this section if the appeal involves a question of liability under section 1879(a)(2) of the Act. (Section 1879(a)(2) generally addresses whether a provider/supplier or beneficiary did not know, orand could not reasonably be expected to know, that the items or services at issue would not be covered by Medicare.)

I waive my right to collect payment from the beneficiary for furnishedthe items or services at issue in this appeal if a determination of liability under at issue involving §1879(a)(2) of the Act is at issue.

SIGNATURE

DATE

Form CMS1696 (07/05) EF (07/222222222205)

CHARGING OF FEES FOR REPRESENTING BENEFICIARIES BEFORE THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES

An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection with an appeal before the Secretary of the Department of Health and Human Services (DHHS) (i.e., at anthe Administrative Law Judge (ALJ) hearing, or Medicare Appeals Council (MAC) review, or a proceeding before an ALJ or the MAC as a result of a remand from federal district court)level is required by law tto obtain approval of the fee in accordance with 42 CFR §405.910(f). A claim that has been remanded by a court to the Secretary for further administrative proceedings is considered to be before the cretary after the remand by the court. 

TThe form, “Petition to Obtain Representative Fee” elicits the information required for a fee petition. It should be completed by the representative and filed with the request for ALJ hearing or request for MAC reviewDHHS. Where a representative has rendered services in a claim before DHHS, the regulations require that the amount of the fee to be charged, if any, for services performed before the Secretary of DHHS be specified. If any fee is to be charged for such services, a petition for approval of that amount must be submitted. 

An Aapproval of a representative’s fee is not required ifwhere  (1) the appellant being represented is a provider or supplier; or(2) where the fee is for services (1) rendered in an official capacity such as that of legal guardian, committee, or similar court appointed representative office and the court has approved the fee in question;  (32) the fee is for representation of a beneficiary in a proceeding in in representing the beneficiary before the federal district court; of above, or (43) the fee is for representation of a beneficiary in a redetermination or reconsiderationin representing the beneficiary in appeals below the ALJ level. If the representative wishes to waive a fee, he or she may do so. Section III on the front of this form can be used for that purpose. In some instances, as indicated on the form, the fee must be waived for representation.

AUTHORIZATION OF FEE

The requirement for the approval of fees ensures that a representative will receive fair value for the services performed before DHHS on behalf of a beneficiary,claimant and provides athe beneficiary while at the same time givingwith a measure of security that the fees are determined to be reasonableto the beneficiaries. In approving a requested fee, the ALJ or MAC considers the nature and type of services performed, the complexity of the case, the level of skill and competence required in rendition of the services, the amount of time spent on the case, the results achieved, the level of administrative review to which the representative carried the appeal and the amount of the fee requested by the representative. 

CONFLICT OF INTEREST

Sections 203, 205 and 207 of Title XVIII of the United States Code make it a criminal offense for certain officers, employees and former officers and employees of the United States to render certain services in matters affecting the Government or to aid or assist in the prosecution of claims against the United States. Individuals with a conflict of interest are excluded from being representatives of beneficiaries before DHHS. WHERE TO SEND THIS FORM

Send this form to the same location where you are sending (or have already sent) your:

appeal if you are filing an appeal, grievance if you are filing a grievance, initial determination or decision if you are requesting an initial determination or decision.

If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1-800-633-4227).

212441850. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09380950. The time required to prepare and distribute this collection is 15 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the beneficiary. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland  

Form CMS1696 (07/05) EF (07/22205)