Appointment of Representative (Beneficiary)

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

OMB: 0938-0950

IC ID: 8804

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

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) Appointment of Representative form_CMS 1696 English_clean2021.pdf Yes Yes Fillable Printable
Form and Instruction CMS-1696 Appointment of Representative (Spanish) CMS_1696Spanish_2021Chgs_CLEAN.docx Yes Yes Fillable Printable

Health Health Care Services

 

27,054 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 27,054 0 0 0 0 27,054
Annual IC Time Burden (Hours) 6,764 0 0 0 0 6,764
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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