Information Collection

Appointment of Representative (Provider Supplier)

IC 185564 under ICR 202406-0938-011 · OMB 0938-0950.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0950 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.