Information Collection

Appointment of Representative (Provider Supplier)

IC 185564 under ICR 202105-0938-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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) Appointment of Representative form_CMS 1696 English_clean2021.pdf	Form and Instruction
CMS-1696 Appointment of Representative (English) Appointment of Representative form_CMS 1696 English_clean2021.pdf	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)	Appointment of Representative form_CMS 1696 English_clean2021.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 243,490

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	243,490	-69,066	312,556
Annual IC Time Burden (Hours)	60,873	-17,266	78,139
Annual IC Cost Burden (Dollars)	0	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.