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)

OMB: 0938-0950

IC ID: 8804

Information Collection (IC) Details

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Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Beneficiary)
 
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 1696version508_11Feb15.pdf Yes No Fillable Fileable

Health Health Care Services

 

40,740 0
   
Individuals or Households
 
   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 40,740 0 0 14,192 0 26,548
Annual IC Time Burden (Hours) 10,185 0 0 3,548 0 6,637
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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