Appointment of Representative (Provider Supplier)

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

OMB: 0938-0950

IC ID: 185564

Information Collection (IC) Details

View Information Collection (IC)

Appointment of Representative (Provider Supplier)
 
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) Appointment of Representative form_CMS 1696 English_clean2021.pdf Yes No Fillable Fileable

Health Health Care Services

 

243,490 0
   
Private Sector Businesses or other for-profits
 
   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 243,490 0 0 -69,066 0 312,556
Annual IC Time Burden (Hours) 60,873 0 0 -17,266 0 78,139
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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