Appointment of Representative (Provider Supplier)

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

OMB: 0938-0950

IC ID: 185564

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 (Spanish) CMS-1696-508_Spanish_2024.docx Form and Instruction