Information Collection Request
Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (CMS-1696)
ICR 202406-0938-011 · OMB 0938-0950 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-0950 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CMS-1696 Appointment of Representative (Beneficiary) |
Form and Instruction | Modified | Repair queued |
| Form CMS-1696 Appointment of Representative (Provider Supplier) |
Form and Instruction | Modified | Repair queued |
 CMS-1696 - Supporting Statement A_.docx |
Supporting Statement A | Uploaded 2024-06-25 | Repair queued |
 CMS 1696 Form Changes Crosswalk2024.pdf |
Supplementary Document | Uploaded 2024-06-21 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 8804 |  Appointment of Representative (Beneficiary) |
Form and Instruction | Modified | |
| 185564 | Appointment of Representative (Provider Supplier) |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-0950 |
| Type of Information Collection | Revision of a currently approved collection |
| Previous ICR Reference No | 202109-0938-017 |
| Agency Tracking No | CM-CPC |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |