Form CMS-1696, Appointment of Representative Instructions
This form contains 27 fields organized into 4 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Appointed Representative | ||
| Enter Signature | Text |
This field is for the signature of the appointed representative. Please enter the representative's signature here.
|
| Enter Date | Text |
This field is for the date when the appointed representative signed the form. Please enter the date in MM/DD/YYYY format.
|
| Party Information | ||
| Enter Name of Party | Text |
Enter the full name of the party seeking representation.
|
| Enter Medicare Number (beneficiary as party) or National Provider Identifier (provider or supplier as party) | Text |
Enter the Medicare Number if the party is a beneficiary, or the National Provider Identifier if the party is a provider or supplier.
|
| Enter Signature of Party Seeking Representation | Text |
Provide the signature of the party seeking representation.
|
| Enter Date | Text |
Enter the date when the party seeking representation signed the form.
|
| Enter Street Address | Text |
Enter the street address of the party seeking representation.
|
| Enter Phone Number (with Area Code) | Text |
Enter the phone number of the party seeking representation, including the area code.
|
| Enter City | Text |
Enter the city of the party seeking representation.
|
| Enter State | Text |
Enter the state of the party seeking representation.
|
| Enter Zip Code | Text |
Enter the zip code of the party seeking representation.
|
| Enter Email Address (optional) | Text |
Enter the email address of the party seeking representation (optional).
|
| Enter Fax Number (optional) | Text |
Enter the fax number of the party seeking representation (optional).
|
| Enter Name of Party in Box 1 at Top of Form | Text |
Enter the name of the party as it appears in Box 1 at the top of the form.
|
| Party Seeking Representation | ||
| Enter Signature | Text |
This field is for the signature of the party seeking representation. Please enter your signature here.
|
| Enter Date | Text |
This field is for the date when the party seeking representation signed the form. Please enter the date in MM/DD/YYYY format.
|
| Representative Information | ||
| Enter Name of Representative | Text |
Enter the full name of the appointed representative.
|
| Enter (Professional status or relationship to the party, e.g. attorney, relative, etc.) | Text |
Enter the professional status or relationship of the representative to the party (e.g., attorney, relative, etc.).
|
| Enter Signature of Representative | Text |
Provide the signature of the appointed representative.
|
| Enter Date | Text |
Enter the date when the appointed representative signed the form.
|
| Enter Street Address | Text |
Enter the street address of the appointed representative.
|
| Enter Phone Number (with Area Code) | Text |
Enter the phone number of the appointed representative, including the area code.
|
| Enter City | Text |
Enter the city of the appointed representative.
|
| Enter State | Text |
Enter the state of the appointed representative.
|
| Enter Zip Code | Text |
Enter the zip code of the appointed representative.
|
| Enter Email Address (optional) | Text |
Enter the email address of the appointed representative (optional).
|
| Enter Fax Number (optional) | Text |
Enter the fax number of the appointed representative (optional).
|