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

dePartMeNt oF HeaLtH aNd HUMaN SerViCeS

Form approved

CeNterS For MediCare & MediCaid SerViCeS

oMB No. 0938-0950

APPOINTMENT OF REPRESENTATIVE

NaMe oF Party

MediCare or NatioNaL ProVider ideNtiFier NUMBer

SECTION I: APPOINTMENT OF REPRESENTATIVE

To be completed by the party seeking representation (i.e., the Medicare beneficiary, the provider or the supplier):

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 Party SeeKiNg rePreSeNtatioN

date

Street addreSS

PHoNe NUMBer (with 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 party’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 oF rePreSeNtatiVe

date

Street addreSS

PHoNe NUMBer (with Area Code)

City

State

ziP

SECTION III: WAIVER OF FEE FOR REPRESENTATION

Instructions: This section must be completed if the representative is required to, or chooses to waive their fee

for representation. (Note that providers or suppliers that are representing a beneficiary and furnished the items

or services may not charge a fee for representation and 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 serving as a representative for a beneficiary to whom they provided items or

services 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, or 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 the items or services at issue in this appeal if a

determination of liability under §1879(a)(2) of the act is at issue.

SigNatUre

date

Form CMS-1696 (10/10)

H0657_3005 Appointment of Representative File & Use MMDDYYYY

Form Cms-1696 - Appointment Of Representative

Related Articles

Related forms

Related Categories