Information Collection

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

IC 185564 under ICR 200807-0938-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
AOR FORM 1696 revisions_redline_031808.doc	Other-Redline
CMS-1696 Appointment of Representative AOR FORM 1696 revisions_clean_031808.doc	Form and Instruction
CROSSWALK DOCUMENT CMS1696_031808.doc CROSSWALK DOCUMENT CMS1696_031808	IC Document

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 405.910

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Redline			AOR FORM 1696 revisions_redline_031808.doc		Yes	Yes	Paper Only
Form and Instruction	CMS-1696	Appointment of Representative	AOR FORM 1696 revisions_clean_031808.doc		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 241,441

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	241,441	241,441
Annual IC Time Burden (Hours)	60,360	60,360
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
CROSSWALK DOCUMENT CMS1696_031808	CROSSWALK DOCUMENT CMS1696_031808.doc	06/16/2008

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.