Get Cms-1696 2024-2025

The CMS-1696 form allows individuals to appoint a representative to act on their behalf for claims, appeals, grievances, or requests related to Medicare. This guide provides clear instructions for completing the form online, ensuring you understand each section and field.

Follow the steps to fill out the CMS-1696 online.

1. Click the ‘Get Form’ button to access the CMS-1696 and open it in your browser.
2. In Section 1, provide all required information about the person appointing the representative, including their name, Medicare number or National Provider Identifier, mailing address, phone number, city, state, email (optional), fax (optional), ZIP code, signature, and date signed in mm/dd/yyyy format.
3. In Section 2, fill out the required details about the representative, such as their name, professional status or relationship to the person in Section 1, mailing address, phone number, city, state, email (optional), fax (optional), and ZIP code. Ensure they sign and date the form.
4. If applicable, complete Section 3 by signing to waive any fees for representation, if the representative has agreed to do so.
5. Similarly, if the appeal concerns payment for items or services, complete Section 4. The representative must sign and date this section as well.
6. Once all sections are filled out, review the form for accuracy and completeness. Save your changes, download, and print the form if needed. You can also choose to share it as required.

Complete your CMS-1696 form online to appoint your representative today!