Yes! You can use AI to fill out Form CMS-1696, Appointment of Representative

CMS-1696 has a Form Complexity Index of 37 out of 100, placing it in the basic complexity tier. This score is calculated deterministically from the form’s own structure using Instafill’s published Form Complexity Index methodology, so it can be reproduced and independently verified — it is not a subjective estimate.

For CMS-1696 specifically, the score reflects 27 fillable fields across 1 page, grouped into 4 sections, plus 1 page of printed instructions. The number of fields is the largest factor in the base score (weighted 36%), followed by how difficult those fields are to complete based on their type, where free-text and signature fields count for more than simple checkboxes (26%). The number of pages that actually contain fields (15%), the amount of conditional “fill-only-if” logic (16%), and how many sections the form is divided into (7%) account for the rest of the base. On top of that base, the index adds points for tables and repeating lists, bundled instruction pages, and dense page layouts — capturing difficulty the base alone can miss.

In practical terms, a basic score means the form is relatively light, but still needs careful, accurate entry. Instafill removes that effort entirely: our AI reads your information, maps each value to the correct field — including the conditional ones — and completes CMS-1696 accurately in under a minute, with every field available for you to review before you download. See exactly how the Form Complexity Index is calculated.

The Appointment of Representative form (CMS-1696) is used when a Medicare beneficiary, provider, or supplier wants to appoint an individual to act on their behalf in connection with a claim or asserted right under Title XVIII of the Social Security Act.

Any individual can be appointed as a representative, provided they are not disqualified, suspended, or prohibited from practice before the Department of Health and Human Services and recognize that any fee may be subject to review and approval by the Secretary.

Section 1 of the form is to be completed by the party seeking representation. It requires the signature, date, and contact information of the party, as well as their Medicare number or National Provider Identifier if applicable.

The representative is authorized to make any request, present or elicit evidence, obtain appeals information, and receive any notice in connection with the claim, appeal, grievance, or request on behalf of the party.

Section 2 of the form is to be completed by the representative accepting the appointment. It requires their signature, date, and contact information, as well as their professional status or relationship to the party.

The completed form should be submitted to the Medicare Administrative Contractor (MAC) or Quality Improvement Organization (QIO) responsible for processing the claim or appeal on behalf of the party.

There may be a fee for appointing a representative, which will be subject to review and approval by the Secretary of the Department of Health and Human Services.

Yes, the appointment can be revoked by the party at any time by submitting a written notice to the MAC or QIO. The representative will also be notified of the revocation.

Yes, 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 HHS is required to obtain approval of the fee in accordance with 42 CFR 405.910.

The representative must complete the OMHA-118 form and file it with the request for ALJ hearing, OMHA review, or request for Medicare Appeals Council review. Approval of a representative’s fee is not required if certain conditions are met.

A conflict of interest exists when certain officers, employees, and former officers and employees of the United States render services in matters affecting the Government or 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 HHS.

The completed form should be sent to the same location where the appeal, grievance, or complaint is being filed, or where the initial determination or decision is being requested.

The instructions and regulation requirements for this form include information on the name and contact information of the party, the appointment of a representative, charging of fees for representation, approval of fees, and conflict of interest.

The valid OMB control number for this information collection is 0938-0950.

The time required to prepare and distribute this form is approximately 15 minutes per notice.

Beneficiaries have the right to get Medicare information in an accessible format and file a complaint if they feel they’ve been discriminated against. They can contact the Centers for Medicare & Medicaid Services (CMS) to file a complaint or request information in an accessible format. CMS provides several ways to file a complaint, including online, by mail, or by phone. The contact information for filing a complaint or requesting information in an accessible format can be found on the CMS website or by contacting the CMS Regional Office.