Crosswalk

2015 (old version)	2017 (new version)	Type of Change	Reason for Change	Burden Change
Page 1, 2nd fill box: Medicare Number (beneficiary as party) or National Provider Identifier Number (provider as party)	Page 1, 2nd fill box: Medicare Number (beneficiary as party) or National Provider Identifier (provider or supplier as party)	Rev	Correction to capitalize first letter of "number" following "Medicare" to indicate the use of a Medicare issued identifier; add "or supplier" following "provider" to comport with regulation at 42 CFR 405.910(c)(5)	No
Page 1, Section 1: I appoint this individual, _________ to act as my representative in connection with my claim or asserted right under Title XVIII of the Social Security Act (the “Act”) and related provisions of Title XI of the Act.	Page 1, Section 1: I appoint this individual,______, to act as my representative in connection with my claim or asserted right under Title XVIII of the Social Security Act (the Act) and related provisions of Title XI of the Act.	Rev	Remove extra spacing prior to, and following the fill line in Section 1; add a comma following the fill ine; remove quotation marks surrounding the word "Act" - aesthetic corrections.	No
Page 1, Section 1: I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my appeal, wholly in my stead. I understand that personal medical information related to my appeal may be disclosed to the representative indicated below.	Page 1, Section 1: I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my claim, appeal, grievance or request wholly in my stead. I understand that personal medical information related to my request may be disclosed to the representative indicated below.	Rev	Added the words "claim, grievance, or request" where the word "appeal" appears for the second time in the sentence to elaborate on the types of notices that may be sent in connection with this appointment instrument; changed the word "appeal" at the end of the sentence to "request" for clarity.	No
Page 1, Section 1: Fill boxes	Page 1, Section 1: Fill boxes: Added a fill box for an optional email address to be included	Rev	Since the last collection package, there has been an increase in communication using email so an optional fill box for email was added	No
Page 1, Section 2: I,_____ , hereby accept the above appointment. I certify that I have not been disqualified, suspended, or prohibited from practice before the Department of Health and Human Services (DHHS);	Page 1, Section 2: I,______, hereby accept the above appointment. I certify that I have not been disqualified, suspended, or prohibited from practice before the Department of Health and Human Services (HHS);	Rev	Corrected acronym from "DHHS" to more commonly used "HHS"	No
Page 1, Section 2: Fill boxes	Page 1, Section 2: Fill boxes: Added a fill box for an optional email address to be included	Rev	Since the last collection package, there has been an increase in communication using email so an optional fill box for email was added	No
Page 1, Section 3: I waive my right to charge and collect a fee for representing before the Secretary of DHHS.	Page 1, Section 3: I waive my right to charge and collect a fee for representing before the Secretary of HHS.	Rev	Corrected acronym from "DHHS" to "HHS"	No
Page 2 - top of page: Charging of Fees for Representing Beneficiaries before the Secretary of DHHS	Page 2 - top of page: Charging of Fees for Representing Beneficiaries before the Secretary of HHS	Rev	Corrected acronym from "DHHS" to "HHS"	No
Page 2 - 1st paragraph: An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection with an appeal before the Secretary of DHHS (i.e., an Administrative Law Judge (ALJ) hearing, Medicare Appeals Council review, or a proceeding before an ALJ or the Medicare Appeals Council as a result of a remand from federal district court) is required to obtain approval of the fee in accordance with 42 CFR 405.910(f).	Page 2 - 1st paragraph: An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection with an appeal before the Secretary of HHS (i.e., an Administrative Law Judge (ALJ) hearing or attorney adjudicator review by the Office of Medicare Hearings and Appeals (OMHA), Medicare Appeals Council review, or a proceeding before OMHA or the Medicare Appeals Council as a result of a remand from federal district court) is required to obtain approval of the fee in accordance with 42 CFR 405.910(f).	Rev	Corrected acronym from "DHHS" to "HHS", added "attorney adjudicator review" following "ALJ hearing" and changed " a proceeding before an ALJ" to " a proceeding before OMHA" to clarify the variety of appellant proceedings at OMHA.	No
Page 2 - 2nd paragraph, 2nd sentence : It should be completed by the representative and filed with the request for ALJ hearing or request for Medicare Appeals Council review.	Page 2 - 2nd paragraph, 2nd sentence : It should be completed by the representative and filed with the request for ALJ hearing, OMHA review, or request for Medicare Appeals Council review.	Rev	Insert the term "OMHA review" following "ALJ hearing" to clarify the variety of appellant proceedings at OMHA.	No
Page 2, 3rd paragraph: The requirement for the approval of fees ensures that a representative will receive fair value for the services performed before DHHS on behalf of a beneficiary, and provides the beneficiary with a measure of security that the fees are determined to be reasonable. In approving a requested fee, the ALJ or Medicare Appeals Council will consider the nature and type of services rendered, the complexity of the case, the level of skill and competence required in rendition of the services, the amount of time spent on the case, the results achieved, the level of administrative review to which the representative carried the appeal and the amount of the fee requested by the representative.	Page 2, 3rd paragraph: The requirement for the approval of fees ensures that a representative will receive fair value for the services performed before HHS on behalf of a beneficiary, and provides the beneficiary with a measure of security that the fees are determined to be reasonable. In approving a requested fee, the OMHA or Medicare Appeals Council will consider the nature and type of services rendered, the complexity of the case, the level of skill and competence required in rendition of the services, the amount of time spent on the case, the results achieved, the level of administrative review to which the representative carried the appeal and the amount of the fee requested by the representative.	Rev	Corrected acronym from "DHHS" to "HHS", changed "ALJ " to " OMHA" to encompass the variety of appellant proceedings at OMHA.	No
Page 2, 4th paragraph: Individuals with a conflict of interest are excluded from being representatives of beneficiaries before DHHS.	Page 2, 4th paragraph: Individuals with a conflict of interest are excluded from being representatives of beneficiaries before HHS.	Rev	Corrected acronym from "DHHS" to "HHS"	No
Page 2, 5th paragraph: Send this form to the same location where you are sending (or have already sent) your: appeal if you are filing an appeal, grievance if you are filing a grievance, initial determination or decision if you are requesting an initial determination or decision. If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1-800-633-4227). TTY users please call 1-877-486-2048.	Page 2, 5th paragraph: Send this form to the same location where you are sending (or have already sent) your: appeal if you are filing an appeal, grievance or complaint if you are filing a grievance or complaint, or an initial determination or decision if you are requesting an initial determination or decision. If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1-800-633-4227). TTY users please call 1-877-486-2048.	Rev	Added "or complaint" following "grievance" to comport with list on Page 1 of this form and to clarify the types of issues that may be covered in connection with this appointment instrument.	No
Page 2, 6th paragraph: CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call: 1-800-MEDICARE or email: [email protected].	Page 2, 6th paragraph: You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you believe you’ve been discriminated against. Visit https://www.cms.gov/about-cms/agency-Information/aboutwebsite/cmsnondiscriminationnotice.html, or call 1-800-MEDICARE (1-800-633-4227) for more information.	Rev	Updated accessibility language as directed by the Office of Hearings and Inquiries/Customer Accessibility Resource Staff Director.	No