Get Cms-1696 2018-2025

Filling out the CMS-1696 form, also known as the Appointment of Representative, is an essential step for individuals seeking assistance with their Medicare claims. This guide provides a step-by-step approach to completing the form online, ensuring clarity and ease of use for everyone involved.

Follow the steps to complete the form correctly.

1. Click the ‘Get Form’ button to access the CMS-1696 online. This action will open the form in your preferred online editor, allowing you to begin filling it out.
2. In Section 1, fill out the appointment details. Enter the name of the individual you are appointing as your representative, as well as the Medicare Number or National Provider Identifier associated with the beneficiary or representative.
3. Sign and date Section 1 to confirm your appointment of the representative. Also, provide your street address, phone number (with area code), city, state, zip code, and an optional email address.
4. In Section 2, the representative must fill out their information. They should write their name, confirm their professional status, and sign and date the section to accept the appointment.
5. If the representative is waiving their fee for representation, they must complete Section 3. They should sign and date this section to confirm they are waiving their right to charge a fee.
6. Section 4 should be filled out if the representative is a provider or supplier involved with an appeal related to payment for items or services. They should sign and date this section if they waive the right to collect payment.
7. Review the entire form for accuracy, ensuring all required fields are filled out completely. Once verified, you can save your changes, download the document, print it, or share it as needed.

Complete and submit your CMS-1696 form online today to ensure proper representation in your Medicare claims process.