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

Appointment of Representative and Supporting Regulations in 42 CFR 405.910

⚠️ Notice: This information collection may be referencing outdated material.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
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

Information Collection (IC) Details

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

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 405.910

Information Collection 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: 26,827	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	26,827	-5,428,634	5,455,461
Annual IC Time Burden (Hours)	6,707	-112	6,819
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.