Form CMS-1696 Appointment of Representative (English)

Form Approved

DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB No. 0938-0950

CENTERS FOR MEDICARE & MEDICAID SERVICES Expires: XX/XX/XXXX

Appointment of Representative

Use this form to appoint a representative to act on your behalf for your claim, appeal, grievance or request. By signing this form and appointing this representative, you agree that the representative will be the main contact and have authority to make requests, present evidence, get information, and receive all communication about your action. This person may see your personal medical information. All fields in Sections 1 and 2 are required unless marked optional.

Section 1: Information about the person appointing the representative

This section must be completed by the patient, provider or other person appointing a representative.

Name		Medicare Number or National Provider Identifier
Street Address		Phone (with Area Code)
City	State		ZIP
Email (optional)		Fax (optional)
Signature			Date

Section 2: Information about the representative

This section must be completed by the representative.

Representative Name

Professional status or relationship to the person in Section 1 (attorney, relative, etc.)

Street Address		Phone (with Area Code)
City	State		ZIP
Email (optional)		Fax (optional)

By signing below, you agree to act as a representative and certify that you haven’t been disqualified, suspended, or prohibited from practice before the Department of Health and Human Services (HHS) or otherwise disqualified from acting as a representative. Any fee to be charged for acting as a representative may be subject to review and approval by the Secretary. If you’re charging a fee, go to instructions on page 2.

Representative must complete the sections below if applicable (go to instructions on page 2) Section 3: Waiver of Fee for Representation

Providers and suppliers who furnished the items or services at issue can’t charge a fee for representation and must sign below to waive their fee. Representatives who choose to waive their fee for representation must also sign below.

I waive my right to charge and collect a fee for representing the person in Section 1 before the Secretary of HHS.

Section 4: Waiver of Payment for Items or Services at Issue

If you’re a provider or supplier and you furnished items or services to the patient you’re representing, if the appeal involves a

question of whether you or the patient didn’t know, or couldn’t reasonably be expected to know, that Medicare wouldn’t cover the items or services.

I waive my right to collect payment from the patient for the items or services at issue in this appeal if a determination of liability under §1879(a)(2) of the Act is made.

Form CMS-1696 (XX/XX) 1

Instructions and Regulation Requirements

Instructions

All fields in Sections 1 and 2 are required unless marked “optional.” If the person or entity appointing a representative doesn’t have a Medicare number or National Provider Identifier, fill in “not applicable.” Go to the regulation at 42 CFR 405.910: ECFR.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-I/section-405.910

Waiver of Fee for Representation Section 3 is required when a representative is required, or has agreed, to waive or not charge a fee for their representation. Waiver of Payment for Items or Services at Issue Section 4 is required if a provider or supplier who furnished items or services to the patient represents the patient and liability (knowledge of non-coverage) under §1879(a) (2) of the Act is at issue in the appeal. Go to 42 CFR 405.910(f).

An appointment of a representative is considered valid for one year from the date this form is signed by both the person appointing a representative and the appointed representative. A completed form can be used for other appeals or actions during the one-year period it’s valid. Unless revoked, the representation is valid for the duration of the claim, appeal, grievance, or request for which it was filed.

Charging Fees for Representing Patients before the Secretary of HHS

An attorney, or other representative for a patient, who wants to charge a fee for services rendered in connection with an appeal before the Secretary of HHS (i.e., an Administrative Law Judge (ALJ) hearing or attorney adjudicator review by the Office of Medicare Hearings and Appeals (OMHA), Medicare Appeals Council review, or a proceeding before OMHA or the Medicare Appeals Council as a result of a remand from federal district court), is required to have the fee approved in accordance with 42 CFR 405.910(f).

The representative should complete the form OMHA-118, “Petition to Obtain Approval of a Fee for Representing a Beneficiary” and file it with the request for ALJ hearing, OMHA review, or request for Medicare Appeals Council review. Fee approval is not required if: (1) the appellant being represented is a provider or supplier; (2) the fee is for services rendered in an official capacity such as that of legal guardian, committee, or similar court-appointed representative, and the court approved the fee; (3) the fee is for representing a patient in a proceeding in federal district court; or (4) the fee is for representing a patient in a redetermination or reconsideration. Representatives are permitted to waive their fee if they choose. Get form OMHA-118 here:

HHS.gov/sites/default/files/OMHA-118.pdf

A provider or supplier who furnished the items or services to a Medicare patient that are the subject of the appeal may represent that patient in an appeal, but the provider or supplier may not charge the beneficiary any fee associated with the representation. (42 CFR 405.910(f)(3).)

Approval of Fee

The fee approval requirement ensures that a representative is paid fairly for their services and that patient fees are reasonable. In approving a requested fee, OMHA or Medicare Appeals Council will consider the nature and type of services rendered, the complexity of the case, the level of skill and competence required, the amount of time spent on the case, the results achieved, the level of administrative review needed, and the amount of the fee requested.

Conflict of Interest

Sections 203, 205 and 207 of Title XVIII of the United States Code make it a criminal offense for certain current and former officers and employees of the United States to render certain services in matters affecting the government or to aid or assist in prosecuting claims against the United States. Individuals with a conflict of interest are excluded from serving as representatives of patients before HHS.

Where to Send This Form

Send this form to the same location you send your claim, appeal, grievance, or request.

Get Help & More Information

For questions about this form, contact your Medicare plan or call 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048.

You have the right to get Medicare information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit Medicare.gov/about-us/accessibility-nondiscrimination- notice, or call 1-800-MEDICARE for more information.

Paperwork Reduction Act: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0950. The time required to prepare and distribute this collection is 15 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the beneficiary. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Form CMS-1696 (XX/XX) 2