Crosswalk

CROSSWALK DOCUMENT FOR CHANGES TO CMS-1696
(APPOINTMENT OF REPRESENTATIVE FORM)
SUBMITTED FOR COLLECTION FEBRUARY 2015

SUMMARY OF CHANGES TO CMS-1696: The form “Appointment of
Representative” is primarily used by Medicare beneficiaries in conjunction with filing
appeals on Medicare claim denials. We are clarifying some language in the fill boxes and
adding information on how to request the form in an alternative format (e.g., Braille,
large print, etc.) in conjunction with Section 504 of the Rehabilitation Act of 1973.

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Page 1, top of page: Changed the 2nd fill in area from “Medicare or National
Provider Identifier Number” to “Medicare Number (beneficiary as party) or
National Provider Identifier Number (provider as party)” for clarity.
Page 1, “Section 2”: Second sentence: Capitalized first letter of the word
“Department,” and; introduced the acronym “DHHS” here (acronym was
formerly introduced on second page of form).
Page 1, “Section 3”: Replaced “Department of Health and Human Services” with
acronym “DHHS.”
Page 2, top of page in TITLE “Charging of Fees for Representing Beneficiaries
Before the Secretary of the Department of Health and Human Services”: Replaced
capital “B” in “Before” with lower case “b” and replaced “Department of Health
and Human Services” with acronym “DHHS.”
Page 2, top of page, 1st section “Charging of Fees for Representing Beneficiaries
Before the Secretary of the Department of Health and Human Services” :
Replaced “Department of Health and Human Services” with acronym “DHHS.”
Page 2, 2nd section, “Authorization of Fees”; Changed title to “Approval of
Fees” to more accurately reflect subject.
Page 2, 4th section, “Where to Send this Form”: Added TTY telephone number
for those with hearing or speech disabilities.
Page 2, under 4th section: Added new information (in accordance with Section
504 of Rehabilitation Act of 1973) on how to request form in alternate formats.