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

Forms and Documents

Document Name	Status
Form CMS-1696 Appointment of Representative (Beneficiary) Form and Instruction	Modified
Form CMS-1696 Appointment of Representative (Provider Supplier) Form and Instruction	Modified
CMS-1696.Justification for a Nonsubstantive Change.docx Justification for No Material/Nonsubstantive Change	2018-07-26
Crosswalk_CMS1696Spanish_2018PRAv508.xlsx Supplementary Document	2018-07-26
CMS-1696 - Supporting Statement A (rev OSORA PRA).docx Supporting Statement A	2018-04-30
Crosswalk_CMS1696_2017PRAv508.xlsx Supplementary Document	2018-04-30

IC Document Collections

IC ID	Document Title	Status
8804	Appointment of Representative (Beneficiary) Form and Instruction	Modified
185564	Appointment of Representative (Provider Supplier) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0950	ICR Reference No: 201807-0938-010
Status: Active	Previous ICR Reference No: 201804-0938-026
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (CMS-1696)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/14/2018
	Date Received in OIRA: 07/27/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2021	07/31/2021	07/31/2021
Responses	347,284	0	347,284
Time Burden (Hours)	86,821	0	86,821
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): 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
   PL: Pub.L. 106 - 554 521 Name of Law: Medicare, Medicaid, and SCHIP Benefits Improvement Act of 2000 (BIPA)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 61002	12/26/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 11207	03/14/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Appointment of Representative (Provider Supplier)	CMS-1696, CMS-1696	Appointment of Representative (English) ,   Nombramiento de un Representante
Appointment of Representative (Beneficiary)	CMS-1696, CMS-1696	Appointment of Representative (English) ,   Nombramiento de un Representante

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ICR Summary of Burden

	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	347,284	347,284	0	0	0	0
Annual Time Burden (Hours)	86,821	86,821	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 07/27/2018

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