Appointment of Representative and Supporting Regulations in 42 CFR 405.910

Forms and Documents

Document	Type	Status	Availability
Form CMS-1696 Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Beneficiary)	Form and Instruction	Modified	Repair queued
Form CMS-1696 Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Provider Supplier)	Form and Instruction	Modified	Repair queued
Summary of Changes (CMS-1696).docx	Supplementary Document	Uploaded 2012-03-13	Available
CMS-1696.Supporting Statement Part A .pdf	Supporting Statement A	Uploaded 2012-03-13	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
8804	Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Beneficiary)	Form and Instruction	Modified
185564	Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Provider Supplier)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0950	ICR Reference No: 201203-0938-007
Status: Historical Active	Previous ICR Reference No: 201006-0938-017
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Appointment of Representative and Supporting Regulations in 42 CFR 405.910
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/08/2012
	Date Received in OIRA: 03/13/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2015	36 Months From Approved
Responses	265,481	0	0
Time Burden (Hours)	66,370	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This form will be completed by beneficiaries, providers and suppliers who wish to appoint representatives to assist them with obtaining initial determinations and filing appeals. The appointment of representative form must be signed by the party making the appointment and the individual agreeing to accept the appointment.

---

Authorizing Statute(s): US Code: 18 USC 1869 Name of Law: BIPA
   PL: Pub.L. 108 - 178 931 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
   PL: Pub.L. 106 - 554 521 Name of Law: Medicare, Medicaid, and SCHIP Benefits Improvement Act of 2000 (BIPA)
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 64213	10/07/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 3477	01/24/2012
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Beneficiary)	CMS-1696	Appointment of Representative
Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Provider Supplier)	CMS-1696	Appointment of Representative

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	265,481	0	0	0	-2,787	268,268
Annual Time Burden (Hours)	66,370	0	0	0	-697	67,067
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/13/2012

---