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

ICR 201507-0938-010

OMB: 0938-0950

Federal Form Document

ICR Details
0938-0950 201507-0938-010
Historical Active 201505-0938-007
HHS/CMS
Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (CMS-1696)
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 11/06/2015
Retrieve Notice of Action (NOA) 07/17/2015
  Inventory as of this Action Requested Previously Approved
06/30/2018 06/30/2018 06/30/2018
407,396 0 407,305
101,849 0 101,849
0 0 0

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.

PL: Pub.L. 106 - 554 521 Name of Law: Medicare, Medicaid, and SCHIP Benefits Improvement Act of 2000 (BIPA)
   PL: Pub.L. 108 - 178 931 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
   US Code: 18 USC 1869 Name of Law: BIPA
  
None

Not associated with rulemaking

  80 FR 10686 02/26/2015
80 FR 26568 05/08/2015
No

  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 407,396 407,305 0 91 0 0
Annual Time Burden (Hours) 101,849 101,849 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
No
No
No
Uncollected
Mitch Bryman 410 786-5258 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
07/17/2015


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