DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB no. 09380950
APPOINTMENT OF REPRESENTATIVE
NAME OF BENEFICIARY
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
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.)
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.
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.
Form CMS1696 (07/05) EF (07/2 2 2 2 2 2 2 2 2 2 0 5)