This form contains 27 fields organized into 5 sections, giving it a Form Complexity Index of 37/100 (basic). Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Fee Waiver for Representation
Party Represented	Text	Enter the name of the party whom the representative is waiving the right to charge a representation fee for representing.
Representative Signature	Text	Provide the representative’s signature to confirm the waiver of the right to charge and collect a fee.
Waiver Signature Date	Date	Enter the date on which the representative signs the fee waiver.
Party Information
Name of Party	Text	Enter the full name of the Medicare beneficiary, provider, or supplier seeking representation.
Medicare Number or National Provider Identifier	Text	Enter the Medicare number of the beneficiary or the National Provider Identifier of the provider or supplier.
Party Seeking Representation
Signature of Party Seeking Representation	Text	Provide the signature of the party appointing a representative.
Appointment Date	Date	Enter the date on which the party signs the appointment.
Street Address	Text	Provide the street address of the party seeking representation.
Phone Number	Text	Provide the telephone number, including the area code, for the party seeking representation.
City	Text	Provide the city where the party seeking representation resides or is located.
State	Text	Provide the state where the party seeking representation resides or is located.
ZIP Code	Text	Provide the ZIP Code for the party's address.
Email Address	Text	Provide the email address of the party seeking representation, if available.
Fax Number	Text	Provide the fax number of the party seeking representation, if available.
Payment Waiver for Items or Services
Signature	Text	Provide the representative’s signature to confirm the waiver of payment for the items or services at issue.
Date	Date	Enter the date the payment waiver is signed.
Representative Acceptance and Information
Representative Name	Text	Enter the full name of the individual accepting the appointment as representative.
Professional Status or Relationship	Text	State the representative’s professional status or relationship to the party, such as attorney or relative.
Representative Signature	Text	Provide the signature of the appointed representative.
Representative Signature Date	Date	Enter the date the representative signs the appointment acceptance.
Representative Street Address	Text	Enter the representative’s complete street address.
Representative Phone Number	Text	Enter the representative’s telephone number, including the area code.
Representative City	Text	Enter the city where the representative resides or maintains the listed address.
Representative State	Text	Enter the state for the representative’s listed address.
Representative ZIP Code	Text	Enter the ZIP Code for the representative’s listed address.
Representative Email Address	Text	Enter the representative’s email address, if available.
Representative Fax Number	Text	Enter the representative’s fax number, if available.

Form CMS-1696, Appointment of Representative (Rev. 09/21) Instructions