Crosswalk

Appointment of Representa�ve CMS-1696 Revision Crosswalk

Change #

Form

1.

CMS-1696

2.

CMS-1696

3.

4.

5.

6.

CMS-1696

CMS-1696

CMS-1696

CMS-1696

Change

Current
Location

Change form expiration date when
approved
Section 1: Moved fill boxes at top of
form to below the text for Section 1
so that all fill boxes are now located
under the heading of "Section 1".

Page 1
bottom left
Section 1,
first page

Section 1: Revised the text that had
previously been located under
Section 1 to now be directly
underneath the form title and located
prior to the Section 1 fill boxes. The
text revision was to make the
instruction simpler and easily
understandable suing plain language.

Section 1,
first page

Section 1: Instruction following the
words "Section 1" changed from "
Appointment of Representative To be
completed by the party seeking
representation (i.e., the Medicare
beneficiary, the provider or the
supplier):" and now reads:
"Information about the person
appointing the representative This
section must be completed by the
patient, provider or other person
appointing a representative."
Section 2, Change heading from
"Acceptance of Appointment To be
completed by the representative:" to
now read "Information about the
representative This section must be
completed by the representative."

Section 1,
first page

Section 2: Moved the signature fill
box to appear beneath all other fill
boxes in Section 2.

Section 2,
first page

Section 2,
first page

Reason
Update for new
collection.
The required
elements for the fill
boxes were not
changed, but the
placement of the
first two fill boxes
(name and
Medicare number or
National Provider
Identifier) was
changed to group all
fill boxes together in
Section 1 for clarity.
The text narrative
now provides an
overall purpose and
instruction for the
entire form in plain
language, instead of
a narrative that is
specific to Section
1.
Instructions were
updated using plain
language to give
directions on who
must complete the
fill boxes in Section
1.

Changes made to
entire statement
using plain
language to clarify
purpose of section
and who must
complete the
information.
Moved signature fill
box to precede the
attestation
statement now

Appointment of Representa�ve CMS-1696 Revision Crosswalk

Change #

7.

8.

9.

10.

11.

12.

Form

Change

Current
Location

Section 2: Moved the narrative text
that had appeared prior to the fill
boxes in Section 2 to now appear
preceding the signature fill box.

Section 2 first page

Section 2: Revised the text now
underneath the signature fill box to
make the attestation statement
simpler and more easily
understandable using plain language.

Section 2 first page

CMS-1696

New heading added following Section
2 "Representative must complete the
sections below if applicable (go to
instructions on page 2)".

Page 1 near center
of page

Section 3 first page

CMS-1696

Section 3 - updated narrative
instructions on who is responsible for
completing this section and the
conditions that apply when it is
applicable.

Section 4 first page

CMS-1696

Section 4 - updated narrative
instructions on who is responsible for
completing this section and the
conditions that apply when it is
applicable.

CMS-1696

Page 2, moved heading "Instructions
and Regulation Requirements" to top
center of page and enclosed with

Page 2,
page
heading

CMS-1696

CMS-1696

Reason
appearing after the
signature fill box.

Moved attestation
statement to
precede the
signature fill box
now appearing at
the end of Section
2.
Changes made
using plain
language to entire
statement to clarify
obligations of the
representative and
disqualifications that
apply.
Add new heading in
plain language that
makes clear that
Sections 3&4 must
be completed by the
representative if
applicable.
Changes made
using plain
language to entire
instructions to clarify
obligations of the
representative to
sign when certain
conditions are
applicable.
Changes made
using plain
language to entire
instructions to clarify
obligations of the
representative to
sign when certain
conditions are
applicable.
Visual format
change t enhance
clarity using plain

Appointment of Representa�ve CMS-1696 Revision Crosswalk

Change #

Form

Change
visual lines to distinguish overall
purpose of page.

13.

14.

15.

16.

17.

CMS-1696

CMS-1696

CMS-1696

CMS-1696

CMS-1696

Current
Location

Reason
language
applications.

Instructions: Updated entire narrative
of instructions using plain language
to clarify and make easier to follow.
Included new information not
previously placed on the instructions
explaining how long the appointment
lasts and use of the form with
multiple filings.

Page 2, top
of page

Revised entire
instruction section
using plain
language to remove
duplicate
information that is
already on page 1
and to clarify
information and
applicable
regulations.
Revised instruction
section using plain
language to clarify
information and
improve readability.

Charging Fees for Representing
Patients before the Secretary of HHS
- Updated wording using plain
language to make section read more
clearly.

Page 2,
center of
page

Approval of Fee - Updated wording
using plain language to make section
read more clearly.

Page 2,
center of
page

Revised instruction
section using plain
language to clarify
information and
improve readability.

Where to Send This Form - Revised
first sentence to now read: Send this
form to the same location you send
your claim, appeal, grievance, or
request. Removed all other
information.
Create new heading "Get Help &
More Information". Placed 1-800MEDICARE contact information
under this new heading for easier
readability. Also included accessibility
statement under this new heading.

Page 2,
bottom of
page

Revised instruction
section using plain
language to clarify
information and
improve readability.

Page 2,
bottom of
page

Create new
instruction section
that houses all
contact information
in one place using
plain language to
clarify information
and improve
readability.