Information Collection

Appointment of Representative (Beneficiary)

IC 8804 under ICR 202109-0938-017 · 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⚠️ Notice: This information collection may be referencing outdated material.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 (Beneficiary)	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
CMS-1696 Appointment of Representative (Spanish) CMS_1696Spanish_2021Chgs_CLEAN.docx	Form and Instruction
CMS-1696 Appointment of Representative (Spanish) CMS_1696Spanish_2021Chgs_CLEAN.docx	Form and Instruction

IC Title:

Appointment of Representative (Beneficiary)

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 27,054

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	27,054	27,054
Annual IC Time Burden (Hours)	6,764	6,764
Annual IC Cost Burden (Dollars)	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.