Form Cms-1696 - Appointment Of Representative - Department Of Health And Human Services Page 2
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2Charging of Fees for Representing Beneficiaries before the Secretary of DHHS
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 DHHS (i.e., an Administrative Law Judge (ALJ) hearing, Medicare Appeals Council review, or a
proceeding before an ALJ or the Medicare Appeals Council 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 Medicare Appeals Council 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.
Approval 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 Medicare Appeals Council will consider the nature and type of services
rendered, 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). TTY users please call
1-877-486-2048.
CMS does not discriminate in its programs and activities. To request this publication in an alternative format, please call:
1-800-MEDICARE or email: AltFormatRequest@cms.hhs.gov.
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 (11/15)
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