Information Collection

Appointment of Representative (Provider Supplier)

IC 185564 under ICR 202508-0938-005 · OMB 0938-0950.

Documents and Forms

Document Name Document Type
Form CMS-1696 Appointment of Representative (Provider Supplier) Form and Instruction
Form CMS-1696 Appointment of Representative (English) Appointment of Representative (Provider Supplier) Form and Instruction
Form CMS-1696 Appointment of Representative (Spanish) Appointment of Representative (Provider Supplier) Form and Instruction
Form CMS-1696 Appointment of Representative (Chinese) Appointment of Representative (Provider Supplier) Form and Instruction
Form CMS-1696 Appointment of Representative (Korean) Appointment of Representative (Provider Supplier) Form and Instruction
Form CMS-1696 Appointment of Representative (Vietnamese) Appointment of Representative (Provider Supplier) Form and Instruction
CMS-1696 Appointment of Representative (English) CMS-1696 Appointment of Representative_English.docx Form and Instruction
CMS-1696 Appointment of Representative (English) CMS-1696 Appointment of Representative_English.docx Form and Instruction
CMS-1696 Appointment of Representative (Spanish) CMS-1696 Appointment of Representative_Spanish.docx Form and Instruction
CMS-1696 Appointment of Representative (Spanish) CMS-1696 Appointment of Representative_Spanish.docx Form and Instruction
CMS-1696 Appointment of Representative (Chinese) CMS-1696 Appointment of Representative_Chinese.docx Form and Instruction
CMS-1696 Appointment of Representative (Chinese) CMS-1696 Appointment of Representative_Chinese.docx Form and Instruction
CMS-1696 Appointment of Representative (Korean) CMS-1696 Appointment of Representative_Korean.docx Form and Instruction
CMS-1696 Appointment of Representative (Korean) CMS-1696 Appointment of Representative_Korean.docx Form and Instruction
CMS-1696 Appointment of Representative (Vietnamese) CMS-1696 Appointment of Representative_Vietnamese.docx Form and Instruction
CMS-1696 Appointment of Representative (Vietnamese) CMS-1696 Appointment of Representative_Vietnamese.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1696	Appointment of Representative (English)	CMS-1696 Appointment of Representative_English.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-1696	Appointment of Representative (Spanish)	CMS-1696 Appointment of Representative_Spanish.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-1696	Appointment of Representative (Chinese)	CMS-1696 Appointment of Representative_Chinese.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-1696	Appointment of Representative (Korean)	CMS-1696 Appointment of Representative_Korean.docx	Yes	Yes	Fillable Printable
Form and Instruction	CMS-1696	Appointment of Representative (Vietnamese)	CMS-1696 Appointment of Representative_Vietnamese.docx	Yes	Yes	Fillable Printable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 187,356	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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	187,356	-4,531	191,887
Annual IC Time Burden (Hours)	46,839	-1,133	47,972
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.

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