PDF
Word
This version of the form is not currently in use and is provided for reference only. Download this version of
Form CMS-1696
for the current year.
Form CMS-1696 Appointment of Representative
What Is Form CMS-1696?
This is a legal form that was released by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services on August 1, 2018 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is Form CMS-1696?A: Form CMS-1696 is the Appointment of Representative form for Medicare.
Q: Who needs to complete Form CMS-1696?A: Medicare beneficiaries who wish to have a representative act on their behalf need to complete this form.
Q: What does a representative do?A: A representative can help with appeals and other Medicare-related matters on behalf of the beneficiary.
Q: Is there a fee to complete Form CMS-1696?A: No, there is no fee to complete Form CMS-1696.
Q: Can I change my representative?A: Yes, you can change your representative at any time by submitting a new Form CMS-1696.
Q: Is my representative required to have legal expertise?A: No, your representative does not need to have legal expertise, but they should have knowledge of Medicare rules and regulations.
Q: Can I appoint more than one representative?A: Yes, you can appoint multiple representatives if you wish.
Q: How long is Form CMS-1696 valid?A: Form CMS-1696 is valid until it is withdrawn or revoked by the beneficiary or their representative.
Form Details:
- Released on August 1, 2018;
- The latest available edition released by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services;
- Easy to use and ready to print;
- Yours to fill out and keep for your records;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form CMS-1696 by clicking the link below or browse more documents and templates provided by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services.
Download Form CMS-1696 Appointment of Representative
1
2
