Get Cms-1696 2010

The CMS-1696 form, also known as the appointment of representative form, is essential for individuals seeking assistance in managing their Medicare claims. This guide will provide clear and organized instructions on how to accurately complete the CMS-1696 online, ensuring a smooth process.

Follow the steps to fill out your CMS-1696 form effectively.

1. Click the 'Get Form' button to obtain the CMS-1696 form and open it in the online editor.
2. In Section I, provide your name and Medicare or National Provider Identifier number. This section is to be completed by the party seeking representation. Clearly appoint the individual who will act as your representative by filling in their name.
3. Next, authorize the representative by allowing them to make requests, present, elicit evidence, and receive notices regarding your appeal. Be sure to understand that personal medical information may be shared with this representative.
4. Sign and date the form in the designated areas provided for the party seeking representation. Ensure to include your complete street address, phone number with area code, city, state, and zip code.
5. Move to Section II, which is for the representative's acceptance of the appointment. The representative must fill in their name and provide their professional status or relationship to you.
6. The representative should sign and date the form, and also include their street address, phone number with area code, city, state, and zip code.
7. If applicable, Section III allows the representative to waive their fee for representation. They must complete this section by indicating they will not charge a fee and provide their signature and date.
8. If the appeal relates to items or services provided, Section IV requires the representative to waive their right to collect payment for those items or services at issue. They should complete this section with their signature and date.
9. Review the completed form carefully for accuracy. After verifying that all sections are filled out correctly, you can save changes, download, print, or share the form as needed.

Start filling out your CMS-1696 form online to ensure your Medicare appeals are managed effectively.