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)