Form Cms-1696 - Appointment Of Representative Template printable pdf download

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES

OMB no. 09380950

APPOINTMENT OF REPRESENTATIVE

NAME OF BENEFICIARY

MEDICARE NUMBER

SECTION I: APPOINTMENT OF REPRESENTATIVE

To be completed by the beneficiary:

I appoint this individual: ___________________________________ to act as my representative in connection with my

claim or asserted right under Title XVIII of the Social Security Act (the “Act”) and related provisions of Title XI of the

Act. I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and

to receive any notice in connection with my appeal, wholly in my stead. I understand that personal medical information

related to my appeal may be disclosed to the representative indicated below.

SIGNATURE OF BENEFICIARY

DATE

STREET ADDRESS

PHONE NUMBER

(AREA CODE)

CITY

STATE

ZIP

SECTION II: ACCEPTANCE OF APPOINTMENT

To be completed by the representative:

I, ________________________________, hereby accept the above appointment. I certify that I have not been disqualified,

suspended, or prohibited from practice before the Department of Health and Human Services; that I am not, as a current or

former employee of the United States, disqualified from acting as the beneficiary’s representative; and that I recognize that

any fee may be subject to review and approval by the Secretary.

I am a / an__________________________________________________________________________________________

(PROFESSIONAL STATUS OR RELATIONSHIP TO THE PARTY, E.G. ATTORNEY, RELATIVE, ETC.)

SIGNATURE

DATE

STREET ADDRESS

PHONE NUMBER

(AREA CODE)

CITY

STATE

ZIP

SECTION III: WAIVER OF FEE FOR REPRESENTATION

Instructions: This form should be filled out if the representative waives a fee for such representation.

(Note that providers or suppliers may not charge a fee for representation and thus, all providers or suppliers that

furnished the items or services at issue must complete this section.)

I waive my right to charge and collect a fee for representing __________________________________________________

before the Secretary of the Department of Health and Human Services.

SIGNATURE

DATE

SECTION IV: WAIVER OF PAYMENT FOR ITEMS OR SERVICES AT ISSUE

Instructions: Providers or suppliers that furnished the items or services at issue must complete this

section if the appeal involves a question of liability under section 1879(a)(2) of the Act. (Section 1879(a)(2)

generally addresses whether a provider/supplier or beneficiary did not know, and could not reasonably be expected to

know, that the items or services at issue would not be covered by Medicare.)

I waive my right to collect payment from the beneficiary for furnished items or services at issue involving 1879(a)(2) of the Act.

SIGNATURE

DATE

Form CMS1696 (07/05) EF (07/2 2 2 2 2 2 2 2 2 2 0 5)

Form Cms-1696 - Appointment Of Representative Template

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