Appointment of Representative (Beneficiary)

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0950 can be found here:

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.