Appointment of Representative (Beneficiary)

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

OMB: 0938-0950

IC ID: 8804

Information Collection (IC) Details

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Appointment of Representative (Beneficiary)
 
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 Appointment of Representative (English) Form 1696version508_2017MEAG_Final.pdf Yes No Printable Only
Form and Instruction CMS-1696 Nombramiento de un Representante CMS_1696Spanish_CLEAN_2018Changes.docx Yes No Fillable Fileable

Health Health Care Services

 

347,284 0
   
Individuals or Households
 
   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 34,728 0 0 0 0 34,728
Annual IC Time Burden (Hours) 8,682 0 0 0 0 8,682
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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