Appointment of Representative (Provider Supplier)

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

OMB: 0938-0950

IC ID: 185564

Information Collection (IC) Details

View Information Collection (IC)

Appointment of Representative (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 Nombramiento de un Representante Clean_2015_CMS_1696_version508_Spanish112515.docx Yes No Fillable Fileable
Form and Instruction CMS-1696 Appointment of Representative (English) Form 1696version508_2017MEAG_Final.pdf Yes No Fillable Fileable

Health Health Care Services

 

347,284 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 312,556 0 0 -54,100 0 366,656
Annual IC Time Burden (Hours) 78,139 0 0 -13,525 0 91,664
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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