Appointment of Representative (Provider Supplier)

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

Documents and Forms

Document Name Document Type
Form CMS-1696 Appointment of Representative (Provider Supplier) Form and Instruction
CMS-1696 Appointment of Representative (English) CMS-1696-508_English_2024.docx Form and Instruction
CMS-1696 Appointment of Representative (English) CMS-1696-508_English_2024.docx Form and Instruction
CMS-1696 Appointment of Representative (Spanish) CMS-1696-508_Spanish_2024.docx Form and Instruction
CMS-1696 Appointment of Representative (Spanish) CMS-1696-508_Spanish_2024.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Appointment of Representative (Provider Supplier)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 405.910

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1696	Appointment of Representative (English)	CMS-1696-508_English_2024.docx		Yes	Yes	Fillable Printable
Form and Instruction	CMS-1696	Appointment of Representative (Spanish)	CMS-1696-508_Spanish_2024.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 191,887	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	191,887	-51,603	243,490
Annual IC Time Burden (Hours)	47,972	-12,901	60,873
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.