Form Cms-1696 - Appointment Of Representative

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Department of Health and Human Services
Form Approved OMB
Centers for Medicare & Medicaid Services
No. 0938-0950
Appointment of Representative
Name of Party
Medicare or National Provider Identifier Number
Section 1: 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
Street Address
Phone Number (with Area Code)
Zip Code
Section 2: Acceptance of Appointment
To be completed by the representative:
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
Street Address
Phone Number (with Area Code)
Zip Code
Section 3: 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.
Section 4: 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.
Form CMS-1696 (Rev 06/12)
H9869_2017_16718_PHP_CMS 1696 AOR


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