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

OMB 0938-0950

This form will be completed by beneficiaries, providers and suppliers who wish to appoint representatives to assist them with obtaining initial determinations and filing appeals. The appointment of representative form must be signed by the party making the appointment and the individual agreeing to accept the appointment.

The latest form for Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (CMS-1696) expires 2021-07-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-1696 Appointment of Representative (Beneficiary) Form and Instruction
Form CMS-1696 Appointment of Representative (Provider Supplier) Form and Instruction
CMS-1696 - Supporting Statement A_.docx Supporting Statement A
CMS 1696 Form Changes Crosswalk2024.pdf Supplementary Document
Appointment of Representative (Beneficiary) Form and Instruction
Appointment of Representative (Provider Supplier) Form and Instruction

All Historical Document Collections

202406-0938-011 Approved without change	Revision of a currently approved collection	2024-06-25
202109-0938-017 Approved without change	No material or nonsubstantive change to a currently approved collection	2021-09-29
202105-0938-010 Approved without change	Revision of a currently approved collection	2021-05-26
201807-0938-010 Approved without change	No material or nonsubstantive change to a currently approved collection	2018-07-27
201804-0938-026 Approved without change	Extension without change of a currently approved collection	2018-04-30
201512-0938-001 Approved without change	No material or nonsubstantive change to a currently approved collection	2015-12-01
201507-0938-010 Approved without change	No material or nonsubstantive change to a currently approved collection	2015-07-17
201505-0938-007 Approved without change	Extension without change of a currently approved collection	2015-05-18
201208-0938-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2012-08-09
201203-0938-007 Approved with change	Reinstatement without change of a previously approved collection	2012-03-13
201006-0938-017 Approved without change	Revision of a currently approved collection	2010-06-30
201006-0938-008 Preapproved	No material or nonsubstantive change to a currently approved collection	2010-06-16
200807-0938-001 Approved with change	Revision of a currently approved collection	2008-07-02
200704-0938-005 Approved without change	No material or nonsubstantive change to a currently approved collection	2007-04-17
200503-0938-008 Approved with change	New collection (Request for a new OMB Control Number)	2005-03-28

OMB Details

Appointment of Representative (Beneficiary)

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-1696	Nombramiento de un Representante	Fillable Fileable	Form and instruction
Form CMS-1696	Appointment of Representative (English)	Printable Only	Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.