Information Collection

Appointment of Representative (Beneficiary)

IC 8804 under ICR 202508-0938-005 · OMB 0938-0950.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-1696 Appointment of Representative (Beneficiary)	Form and Instruction
Form CMS-1696 Appointment of Representative (English) Appointment of Representative (Beneficiary)	Form and Instruction
Form CMS-1696 Appointment of Representative (Spanish) Appointment of Representative (Beneficiary)	Form and Instruction
Form CMS-1696 Appointment of Representative (Chinese) Appointment of Representative (Beneficiary)	Form and Instruction
Form CMS-1696 Appointment of Representative (Korean) Appointment of Representative (Beneficiary)	Form and Instruction
Form CMS-1696 Appointment of Representative (Vietnamese) 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 (English) CMS-1696-508_English_2024.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 (Beneficiary)

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1696	Yes	Yes	Fillable Printable
Form and Instruction	CMS-1696	Yes	Yes	Fillable Printable
Form and Instruction	CMS-1696	Yes	Yes	Fillable Printable
Form and Instruction	CMS-1696	Yes	Yes	Fillable Printable
Form and Instruction	CMS-1696	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: 20,817

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	20,817	-504	21,321
Annual IC Time Burden (Hours)	5,204	-126	5,330
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.

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