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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 185564 under ICR 201208-0938-004 · OMB 0938-0950.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Provider Supplier)
 
No Modified
 
Voluntary
 
42 CFR 405.910

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-1696 Appointment of Representative CMS-1696.Instrument (6-7-12).pdf Yes No Fillable Fileable
Form and Instruction CMS-1696 Appointment of Representative (Spanish Version) 1696version508_Spanish.docx Yes No Fillable Fileable

Health Health Care Services

 

238,933 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 238,933 0 0 0 0 238,933
Annual IC Time Burden (Hours) 59,733 0 0 0 0 59,733
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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