Information Collection

Appointment of Representative (Provider Supplier)

IC 185564 under ICR 201807-0938-010 · OMB 0938-0950.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0950 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1696 Appointment of Representative (Provider Supplier)	Form and Instruction
CMS-1696 Appointment of Representative (English) Form 1696version508_2017MEAG_Final.pdf	Form and Instruction
CMS-1696 Nombramiento de un Representante CMS_1696Spanish_CLEAN_2018Changes.docx	Form and Instruction

IC Title:

Appointment of Representative (Provider Supplier)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 405.910

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1696	Appointment of Representative (English)	Form 1696version508_2017MEAG_Final.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-1696	Nombramiento de un Representante	CMS_1696Spanish_CLEAN_2018Changes.docx		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 347,284

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	312,556	312,556
Annual IC Time Burden (Hours)	78,139	78,139
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.