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Appointment of Representative (Beneficiary)
Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (CMS-1696)
OMB: 0938-0950
IC ID: 8804
OMB.report
HHS/CMS
OMB 0938-0950
ICR 202406-0938-011
IC 8804
( )
Documents and Forms
Document Name
Document Type
Form CMS-1696
Appointment of Representative (Beneficiary)
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
Information Collection (IC) Details
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