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How to fill out the CMS-1696 online
The CMS-1696 form is essential for appointing a representative in connection with Medicare appeals. This guide provides a clear, step-by-step approach to successfully completing the form online.
Follow the steps to confidently complete the CMS-1696 form.
- Click ‘Get Form’ button to obtain the CMS-1696 form and open it in the editor.
- In Section 1, enter your name and specify if you are the Medicare beneficiary or the provider. Include the Medicare number or National Provider Identifier Number as applicable. Appoint your representative by providing their name and sign the section to authorize them to act on your behalf.
- In Section 2, the appointed representative must accept the appointment. They should fill in their name and professional status or relationship to the party, such as 'attorney' or 'relative.' The representative needs to provide their signature and date, as well as their contact information including street address, phone number, city, state, and zip code.
- If the representative waives their fee for services, they should complete Section 3 by signing and dating the waiver of fee for representation, indicating their agreement to not charge for their services.
- In Section 4, if applicable, the representative will need to waive their right to collect payment for items or services at issue in the appeal. They should provide their signature and date this section as well.
- Review all entered information for accuracy. Once you are satisfied with the completed form, you can save changes, download, print, or share the form as needed.
Complete the CMS-1696 form online to ensure your representation requests are processed efficiently.
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