Crosswalk

CMS-1696 Form Changes Crosswalk
Change
Form
#
1

Current
Location

1696

Change form expiration date to 2023.

1696

In Section 1: First sentence following
instruction, change from: "I appoint the
individual,____________ , to act as my
representative in connection with my
claim…", remove the blank line and
requirement to enter a name and alter
language to now read: "I appoint the
individual named in Section 2 to act as
my representative in connection with
my claim..."

1696

Section 1: Last line of section, shorten
the space to fill in an email address and
add a space to fill in a fax number.
Make both enclosed fill boxes, rather
than lines.

Section 1, first
page

1696

Section 2, first sentence following
instruction, change the line following "I"
in: "I,____________, hereby accept the
above appointment." from a line to a
defined fill box .
Section 2: Last line of section, shorten
the space to fill in an email address and
add a space to fill in a fax number.
Make both enclosed fill boxes, rather
than lines.

Section 2, first
page

Add the header "Instructions and
Regulation Requirements" at top of
page.

Page 2 - top
of page

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3

4
1696

5

1696
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Change

Page 1, top
right hand
corner
Section 1, first
page

Section 2, first
page

Reason
Update for new
collection.
For clarity and ease
of use, remove the
requirement to add
the name of the
individual appointed
here. This name is
already given in
Section 2, so a
reference here to
where the name can
be found on the
page is sufficient.
To provide space for
a fax number,
typically a more
secure method than
email, to transmit
sensitive
information related
to appeals.
To make the fill
space more visually
noticeable.
To provide space for
a fax number,
typically a more
secure method than
email, to transmit
sensitive
information related
to appeals.
Insert a heading to
describe the
information
contained in new
first paragraph on
page 2 for clarity.

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CMS-1696 Form Changes Crosswalk
Change
Form
#
1696

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1696

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1696
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1696
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1696

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Change
Add instructions under header
"Instructions and Regulation
Requirements" on how to complete the
first 2 fill boxes on page 1 at top of
form, and clarify that all fill boxes in
sections 1 & 2 are required to be
completed unless indicated that
information is optional.
Update information under header
"Charging of Fees for Representing
Beneficiaries before the Secretary of
HHS": Change first sentence in second
paragraph in section to read: The form,
OMHA-118, “Petition to Obtain
Approval of a Fee for Representing a
Beneficiary” elicits the information
required for a fee petition.
Update information under header
"Charging of Fees for Representing
Beneficiaries before the Secretary of
HHS": Remove last sentence (no longer
applicable with new form), and replace
with URL for form OMHA-118.
Under header "Where to Send This
Form" revise last sentence so that 1-800
MEDICARE TTY phone number is
following the regular phone number for
clarity.
Page 2, bottom of page, update the
accessibility language per the Office of
Hearings and Inquiries/CARS. UPDATED
LANGUAGE (changes in red font): 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
feel you’ve been discriminated against.
Visit https://www.medicare.gov/aboutus/accessibility-nondiscriminationnotice, or call 1-800-MEDICARE (1-800633-4227) for more information. TTY
users can call 1-877-486-2048.

Current
Location

Reason

Page 2 - top
of page

To clarify what is
required
information and
what is optional.

Page 2 - near
top of page

Update information
with new form,
OMHA-118, used to
file for approval of
charging a fee in
Medicare appeals.

Page 2 - near
top of page

Remove outdated
form instruction,
and replace with
URL of new form.

Page 2 - near
bottom of
page

Revise placement of
telephone numbers
for 1-800-MEDICARE

Page 2,
bottom of
page.

Updated
accessibility and
discrimination
statement required
per OHI/CARS.

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