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Ative to act on your behalf for your claim, appeal, grievance or request. By signing this form and appointing this representative, you agree that the representative will be the main contact and have authority to make requests, present evidence, get information, and receive all communication about your action. This person may see your personal medical information. All fields in Sections 1 and 2 are required unless marked optional. Section 1: Information about the person appointing the representa.

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An appointed representative may act on behalf of an individual or entity in exercising his or her right to an initial determination or appeal.

CMS1696: Appointment of Representative.

Form SSA-1696 | Claimant's Appointment of a Representative. If you have a case before us and need assistance, you can appoint a representative to help you. Your representative can be an attorney or a non-attorney, but must be qualified and comply with our published rules of conduct.

An appointment of a representative is considered valid for one year from the date this form is signed by both the person appointing a representative and the appointed representative.

CMS1696: Appointment of Representative. Department of Health and Human Services. Centers for Medicare & Medicaid Services.

A signed Appointment of Representative Form or an equivalent written notice must include the following: Medicare plan member's or enrollee's name. Medicare plan member's or enrollee's address. Medicare plan member's or enrollee's phone number. Medicare plan member's or enrollee's Health Insurance Claim Number (HICN)

Form SSA-1696 | Claimant's Appointment of a Representative. If you have a case before us and need assistance, you can appoint a representative to help you. Your representative can be an attorney or a non-attorney, but must be qualified and comply with our published rules of conduct.

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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