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

Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (CMS-1696)

⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-1696 Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Beneficiary) Form and Instruction
CMS-1696 Appointment of Representative 1696version508_11Feb15.pdf Form and Instruction
CROSSWALK DOCUMENT CMS1696_V508.pdf Crosswalk IC Document
1696version508_redline27Jan15.docx Track Changes - Redline/Strikeout 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
Form and Instruction	CMS-1696	Appointment of Representative	1696version508_11Feb15.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40,740	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	40,740	14,192	26,548
Annual IC Time Burden (Hours)	10,185	3,548	6,637
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	CROSSWALK DOCUMENT CMS1696_V508.pdf	05/18/2015
Track Changes - Redline/Strikeout	1696version508_redline27Jan15.docx	05/18/2015

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