CMS-1696. Crosswalk of Non-sub changes for Spanish Language Version

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Overview

CMS-1696
Sheet1

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Sheet 1: CMS-1696

2015 (old version)	2018 (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	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 line; 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

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Sheet 2: Sheet1

2015 (old Spanish version)	2018 (new Spanish version)	Type of Change	Reason for Change	Burden Change
Page 1, 2nd fill box: Numero de Medicare (beneficiario como parte) o identificador Nacional del Proveedor (proveedor como parte)	Page 1, 2nd fill box: Numero de Medicare (beneficiario como parte) o identificador Nacional del Proveedor (proveedor o suplidor como parte)	Rev	Add "or supplier" following "provider" to comport with regulation at 42 CFR 405.910(c)(5)	No
Page 1, Section 1: Yo nombro a __________ para actuar como representante en relación con mi reclamación o derecho en virtud del título XVIII de la Ley del Seguro Social (la "Ley") y sus disposiciones relacionadas al título XI de la Ley.	Page 1, Section 1: Yo nombro a __________, para actuar como representante en relación con mi reclamación o derecho en virtud del título XVIII de la Ley del Seguro Social (la Ley) y sus disposiciones relacionadas al título XI de la Ley.	Rev	Remove extra spacing prior to, and following the fill line in Section 1; add a comma following the fill line; remove quotation marks surrounding the word "Act" - aesthetic corrections.	No
Page 1, Section 1: Autorizo a este individuo a realizar cualquier solicitud; presentar u obtener pruebas; obtener información sobre apelaciones y recibir toda notificación sobre mi apelación, en mi representación. Entiendo que podría divulgarse la información médica personal sobre mi apelación al representante indicado a continuación.	Page 1, Section 1: Autorizo a este individuo a realizar cualquier solicitud; presentar u obtener pruebas; obtener información sobre apelaciones; y recibir toda notificación sobre mi reclamación, apelación, queja o solicitud en mi representación. Entiendo que podría divulgarse la información médica personal sobre mi solicitud al representante indicado a continuación.	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: Certifico que no se me ha descalificado, suspendido o prohibido mi desempeño profesional ante el Departamento de Salud y Servicios Humanos (DHHS en inglés);	Page 1, Section 2:Certifico que no se me ha descalificado, suspendido o prohibido mi desempeño profesional ante el Departamento de Salud y Servicios Humanos (HHS en inglés);	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: Renuncio a mi derecho de cobrar un honorario por representar a ante el Secretario(a) del DHHS.	Page 1, Section 3: Renuncio a mi derecho de cobrar un honorario por representar a ante el Secretario(a) del HHS.	Rev	Corrected acronym from "DHHS" to "HHS."	No
Page 2 - top of page: Cobro de Honorarios por Representación de Beneficiarios ante el Secretario(a) del DHHS	Page 2 - top of page: Cobro de Honorarios por Representación de Beneficiarios ante el Secretario(a) del HHS	Rev	Corrected acronym from "DHHS" to "HHS."	No
Page 2 - 1st paragraph: Un abogado u otro representante de un beneficiario, que desee cobrar un honorario por los servicios prestados en relación con una apelación ante el Secretario(a) del DHHS (i.e., una audiencia con un Juez de Derecho Administrativo (ALJ en inglés), una revisión con el Consejo de Apelaciones de Medicare o un proceso ante un ALJ o el Consejo de Apelaciones de Medicare como resultado de una orden de remisión de la Corte de Distrito Federal) debe, por ley obtener aprobación para recibir un honorario de acuerdo con 42 CFR §405.910(f).	Page 2 - 1st paragraph: Un abogado u otro representante de un beneficiario, que desee cobrar un honorario por los servicios prestados en relación con una apelación ante el Secretario(a) del HHS (i.e., una audiencia con un Juez de Derecho Administrativo (ALJ en inglés) o la revisión de un abogado adjudicador por la Oficina de Audiencias y Apelaciones de Medicare (OMHA en inglés), una revisión con el Consejo de Apelaciones de Medicare o un proceso ante OMHA o el Consejo de Apelaciones de Medicare como resultado de una orden de remisión de la Corte de Distrito Federal) debe por ley obtener aprobación para recibir un honorario de acuerdo con 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 : Debe ser completado por el representante y presentado con la solicitud para audiencia con el ALJ o revisión del Consejo de Apelaciones de Medicare.	Page 2 - 2nd paragraph, 2nd sentence : Debe ser completado por el representante y presentado con la solicitud para audiencia con el ALJ revisión de OMHA o revisión del Consejo de Apelaciones de Medicare.	Rev	Insert the term "OMHA review" following "ALJ hearing" to clarify the variety of appellant proceedings at OMHA.	No
Page 2, 3rd paragraph: El requisito para la aprobación de honorarios garantiza que el representante recibirá una remuneración justa por los servicios prestados ante DHHS en nombre de un beneficiario y brinda al beneficiario la seguridad de que los honorarios sean razonables. Para la aprobación de un honorario solicitado, el ALJ o el Consejo de Apelaciones de Medicare considera la clase y el tipo de servicios prestados, la complejidad del caso, el nivel de pericia y capacidad necesaria para la prestación de servicios, la cantidad de tiempo dedicado al caso, los resultados alcanzados, el nivel de revisión administrativa al cual el representante llevó la apelación y el monto del honorario solicitado por el representante.	Page 2, 3rd paragraph: El requisito para la aprobación de honorarios garantiza que el representante recibirá una remuneración justa por los servicios prestados ante HHS en nombre de un beneficiario y brinda al beneficiario la seguridad de que los honorarios sean razonables. Para la aprobación de un honorario solicitado, OMHA o el Consejo de Apelaciones de Medicare considera la clase y el tipo de servicios prestados, la complejidad del caso, el nivel de pericia y capacidad necesaria para la prestación de servicios, la cantidad de tiempo dedicado al caso, los resultados alcanzados, el nivel de revisión administrativa al cual el representante llevó la apelación y el monto del honorario solicitado por el representante.	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: Los individuos con un conflicto de interés quedarán excluidos de ser representantes de los beneficiarios ante DHHS.	Page 2, 4th paragraph: Los individuos con un conflicto de interés quedarán excluidos de ser representantes de los beneficiarios ante HHS.	Rev	Corrected acronym from "DHHS" to "HHS."	No
Page 2, 5th paragraph: Envíe este formulario al mismo lugar que está enviando (o ha enviado) su: apelación si está solicitando una apelación, queja si está solicitando una queja, o determinación o decisión inicial si está solicitando una determinación o decisión inicial. Si necesita ayuda, comuníquese con su plan de Medicare o llame al 1-800-MEDICARE (1-800-633-4227).	Page 2, 5th paragraph: Envíe este formulario al mismo lugar que está enviando (o ha enviado) su: apelación si está solicitando una apelación, queja o protesta si está solicitando una queja o protesta, o determinación o decisión inicial si está solicitando una determinación o decisión inicial. Si necesita ayuda, comuníquese con 1-800-MEDICARE (1-800-633-4227) o con su plan de Medicare.	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 no discrimina en sus programas o actividades. Para solicitar una esta publicación en un formato alterno, llame al 1-800-MEDICARE (TTY 1-877-486-2048) o envíe un correo electrónico a: [email protected].	Page 2, 6th paragraph: Usted tiene derecho a obtener la información de Medicare en un formato accesible, como en letra grande, Braille o audio. También tiene el derecho de presentar una queja si piensa que ha sido discriminado. Visite https://www.cms.gov/about-cms/agency-information/aboutwebsite/cmsnondiscriminationnotice.html o llame al 1-800-MEDICARE para más información.	Rev	Updated accessibility language as directed by the Office of Hearings and Inquiries/Customer Accessibility Resource Staff Director.	No