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

ICR 202406-0938-011

OMB: 0938-0950

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-1696 Appointment of Representative (Beneficiary) Form and Instruction	Modified
Form CMS-1696 Appointment of Representative (Provider Supplier) Form and Instruction	Modified
CMS-1696 - Supporting Statement A_.docx Supporting Statement A	2024-06-25
CMS 1696 Form Changes Crosswalk2024.pdf Supplementary Document	2024-06-21

IC Document Collections

IC ID	Document Title	Status
8804	Appointment of Representative (Beneficiary) Form and Instruction	Modified
185564	Appointment of Representative (Provider Supplier) Form and Instruction	Modified