Form Cms-1696 - Appointment Of Representative Template (Page 2 of 2) in pdf

CHARGING OF FEES FOR REPRESENTING BENEFICIARIES BEFORE

THE SECRETARY OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES

An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection

with an appeal before the Department of Health and Human Services (DHHS) at the Administrative Law Judge (ALJ)

or Medicare Appeals Council (MAC) level is required by law to obtain approval of the fee in accordance with 42 CFR

§405.910(f). A claim that has been remanded by a court to the Secretary for further administrative proceedings is

considered to be before the Secretary after the remand by the court.

The form, “Petition to Obtain Representative Fee” elicits the information required for a fee petition. It should be

completed by the representative and filed with DHHS. Where a representative has rendered services in a claim before

DHHS, the regulations require that the amount of the fee to be charged, if any, for services performed before the

Secretary of DHHS be specified. If any fee is to be charged for such services, a petition for approval of that amount

must be submitted.

An approval of a fee is not required where the appellant is a provider or supplier or where the fee is for services (1)

rendered in an official capacity such as that of legal guardian, committee, or similar courtappointed office and the court

has approved the fee in question; (2) in representing the beneficiary before the federal district court of above, or (3)

in representing the beneficiary in appeals below the ALJ level. If the representative wishes to waive a fee, he or she

may do so. Section III on the front of this form can be used for that purpose. In some instances, as indicated on the

form, the fee must be waived for representation.

AUTHORIZATION OF FEE

The requirement for the approval of fees ensures that representative will receive fair value for the services performed

before DHHS on behalf of a claimant while at the same time giving a measure of security to the beneficiaries. In

approving a requested fee, the ALJ or MAC considers the nature and type of services performed, the complexity of the

case, the level of skill and competence required in rendition of the services, the amount of time spent on the case, the

results achieved, the level of administrative review to which the representative carried the appeal and the amount of the

fee requested by the representative.

CONFLICT OF INTEREST

Sections 203, 205 and 207 of Title XVIII of the United States Code make it a criminal offense for certain officers,

employees and former officers and employees of the United States to render certain services in matters affecting the

Government or to aid or assist in the prosecution of claims against the United States. Individuals with a conflict of

interest are excluded from being representatives of beneficiaries before DHHS.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.

The valid OMB control number for this information collection is 09380950. The time required to prepare and distribute this collection is 15 minutes per notice,

including the time to select the preprinted form, complete it and deliver it to the beneficiary. If you have comments concerning the accuracy of the time estimates or

suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland

212441850.

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