Fillable Form Cms-1696 - Appointment Of Representative (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 Secretary of the department of Health and Human Services (dHHS) (i.e.,

an administrative Law Judge (aLJ) hearing, Medicare appeals Council (MaC) review, or a proceeding before an

aLJ or the MaC as a result of a remand from federal district court) is required to obtain approval of the fee in

accordance with 42 CFr §405.910(f).

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 the request for aLJ hearing or request for MaC review

approval of a representative’s fee is not required if (1) the appellant being represented is a provider or supplier;

(2) the fee is for services rendered in an official capacity such as that of legal guardian, committee, or similar

court appointed representative and the court has approved the fee in question; (3) the fee is for representation

of a beneficiary in a proceeding in federal district court; or (4) the fee is for representation of a beneficiary in a

redetermination or reconsideration. 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 a representative will receive fair value for the services

performed before dHHS on behalf of a beneficiary, and provides the beneficiary with a measure of security

that the fees are determined to be reasonable. 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.

WHERE TO SEND THIS FORM

Send this form to the same location where you are sending (or have already sent) your appeal if you are filing

an appeal, grievance if you are filing a grievance, initial determination or decision if you are requesting an initial

determination or decision.

if additional help is needed, contact your Medicare plan or 1-800-MediCare (1-800-633-4227).

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 0938-0950. 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 21244-1850.

Form CMS-1696 (10/10)

H0657_3005 Appointment of Representative File & Use MMDDYYYY

Form Cms-1696 - Appointment Of Representative Page 2