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Get Department Of Health And Human Services Form 0938 0950

DePartMeNt oF HeaLtH aNd HUMaN SerViCeS CeNterS For MediCare MediCaid SerViCeS Form approved oMB No. 0938-0950 APPOINTMENT OF REPRESENTATIVE NaMe oF Party MediCare or NatioNaL ProVider ideNtiFier NUMBer SECTION I 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 ri.

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Guidance for Medicare beneficiaries. This document is CMS Form 1696 Appointment of Representative, large print version. Issued by: Centers for Medicare & Medicaid Services (CMS)

This form will be completed by beneficiaries, providers and suppliers who wish to appoint representatives to assist them with obtaining initial determinations and filing appeals.

If you want to let someone represent you in a Medicare appeal or grievance, use this form. Do you need someone to file a complaint or appeal for you? If so, this document allows you to name someone to make decisions for you. This person is often a relative, friend, lawyer or doctor.

To appoint a representative, you or your representative should complete the form entitled: Appointment of Representative - CMS-1696 - PDF.

The designated partnership representative remains in effect until the designation is terminated by a valid revocation, a valid resignation, or a determination by the IRS that the designation is not in effect.

Someone who you choose to act on your behalf with the Marketplace, like a family member or other trusted person.

ing to Medicare guidelines, an appointed representative is a person who can act on your behalf to request an exception, appeal or grievance.

You can use the Appointment of Representative (AOR) form CMS-1696* or you can make your own statement (an equivalent written notice) as long as it contains all the required information. In addition, we may also accept other forms of legal documentation.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232