OMB control number
Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (CMS-1696)
OMB 0938-0950 · HHS/CMS.
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 2028-12-31 and is listed under ICR 202608-0938-011.
Latest Forms, Documents, and Supporting Material
Form CMS-1696 Appointment of Representative (Vietnamese)
Appointment of Representative (Beneficiary)All Historical Document Collections
OMB Details
Appointment of Representative (Beneficiary)
Federal Enterprise Architecture: Health - Health Care Services
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form CMS-1696 | Appointment of Representative (English) | Fillable Printable | Form and instruction |
| Form CMS-1696 | Appointment of Representative (Vietnamese) | Fillable Printable | Form and instruction |
| Form CMS-1696 | Appointment of Representative (Korean) | Fillable Printable | Form and instruction |
| Form CMS-1696 | Appointment of Representative (Chinese) | Fillable Printable | Form and instruction |
| Form CMS-1696 | Appointment of Representative (Spanish) | Fillable Printable | Form and instruction |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.