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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-1696 Appointment of Representative (Spanish)	Form and Instruction	Modified	Available
Form CMS-1696 Appointment of Representative (English)	Form and Instruction	Modified	Available
Form CMS-1696 Appointment of Representative (Beneficiary)	Form and Instruction	Modified	Repair queued
Form CMS-1696 Appointment of Representative (Spanish)	Form and Instruction	Modified	Available
Form CMS-1696 Appointment of Representative (English)	Form and Instruction	Modified	Available
Form CMS-1696 Appointment of Representative (Provider Supplier)	Form and Instruction	Modified	Available
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

Information collection document groups

IC ID	Collection	Type	Status	Form
8804	Appointment of Representative (Beneficiary)	Form and Instruction	Modified	Appointment of Representative (Spanish)
8804	Appointment of Representative (Beneficiary)	Form and Instruction	Modified	Appointment of Representative (English)
8804	Appointment of Representative (Beneficiary)	Form and Instruction	Modified
185564	Appointment of Representative (Provider Supplier)	Form and Instruction	Modified	Appointment of Representative (Spanish)
185564	Appointment of Representative (Provider Supplier)	Form and Instruction	Modified	Appointment of Representative (English)
185564	Appointment of Representative (Provider Supplier)	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0950	ICR Reference No: 202406-0938-011
Status: Historical Active	Previous ICR Reference No: 202109-0938-017
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (CMS-1696)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/28/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/25/2024
Terms of Clearance: Prior to the re-submission of this information collection (IC), CMS will assess linguistic preferences across the respondent population and translate this IC into additional languages as appropriate in order to increase accessibility and reduce health disparities. It is the expectation that CMS will translate this form into more languages that English and Spanish, but the number of additional languages will be based on the agency’s assessment of population needs, but these languages could include both Traditional and Simplified Chinese, Vietnamese, Korean, Tagalog, Arabic, French, and Russian. This request is supported by the principles and priorities set forth in the memorandum titled “Improving Access to Public Benefits Programs Through the Paperwork Reduction Act” (April 13, 2022), the Executive Order 13985 on “Advancing Racial Equity and Support for Underserved Communities Through the Federal Government” (January 20, 2021), Executive Order 13166, "Improving Access to Services for Persons with Limited English Proficiency" (August, 11, 2000) and the culturally and linguistically appropriate services (CLAS) standards.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2025	36 Months From Approved	09/30/2024
Responses	213,208	0	270,544
Time Burden (Hours)	53,302	0	67,637
Cost Burden (Dollars)	0	0	0

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Abstract: This form will be completed by beneficiaries, providers and suppliers who wish to appoint representatives to assist them with obtaining initial determinations and filing appeals. The appointment of representative form must be signed by the party making the appointment and the individual agreeing to accept the appointment.

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Authorizing Statute(s): PL: Pub.L. 106 - 554 521 Name of Law: Medicare, Medicaid, and SCHIP Benefits Improvement Act of 2000 (BIPA)
   PL: Pub.L. 108 - 178 931 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
   US Code: 18 USC 1869 Name of Law: BIPA
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 25879	04/12/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 53107	06/25/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Appointment of Representative (Beneficiary)	CMS-1696, CMS-1696	Appointment of Representative (English) ,   Appointment of Representative (Spanish)
Appointment of Representative (Provider Supplier)	CMS-1696, CMS-1696	Appointment of Representative (English) ,   Appointment of Representative (Spanish)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	213,208	270,544	0	0	-57,336	0
Annual Time Burden (Hours)	53,302	67,637	0	0	-14,335	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Current appeals data indicates that the number of first level appeals has decreased since 2021. While the total time to complete the form has not changed, the hourly burden estimates have decreased and is being adjusted in this iteration for all respondents due to a fewer number of appeals being filed. Overall, the number of appeals using this collection has decreased by 57,336 (prior amount 270,544 minus current amount 213,208) which translates to a decrease of 14,335 burden hours (prior amount 67,637 minus current amount 53,302).

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Annual Cost to Federal Government: $1,324

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/25/2024

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