CMS Pub. 100-04, ch. 29, § 270.1.2

The party making the appointment and the individual accepting the appointment must either complete an

appointment of representative form (CMS-1696) or use a conforming written instrument (see subsection B

below, for required elements of written instruments). A party may appoint a representative to assist with

filing a claim, or at any time during the course of an appeal. In order to constitute a valid appointment, the

CMS-1696 or other conforming written instrument must contain signatures of the representative and the

party. By signing the appointment, the representative indicates his/her acceptance of being appointed as

representative. The form CMS-1696 can be found at: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012207.html

All signatures may be handwritten or electronic, digital, and/or digitized. Electronic, digital, and/or

digitized signatures are acceptable for appointment of representative instruments submitted via mail,

facsimile, or a CMS-approved secure Internet portal/application.

CMS permits the use of a rubber stamp in lieu of a handwritten signature in accordance with the

Rehabilitation Act of 1973 in the case of an author with a physical disability that can provide proof to a

CMS contractor of his or her inability to sign their signature due to their disability. By affixing the rubber

stamp, the person is certifying that they have reviewed the document.

A. Completing a Valid Appointment of Representative (Form CMS-1696)

The CMS-1696 is available for the convenience of the beneficiary or any other party to use when appointing

a representative. Following are instructions for completing the form.

1. The name of the party making the appointment must be clearly legible. If the party being represented

is the beneficiary, the Medicare number must be provided. If the party being represented is a

provider or supplier, the National Provider Identifier number must be provided. If the party being

represented is an applicable plan in an appeal under 42 CFR §405.924(b)(16), the space may be left

blank. A Medicare number is required only when the beneficiary is the party appointing a

representative.

2. Completing Section I – “Appointment of Representative”- The party making the appointment

includes their signature, address, and phone number. If the party that wishes to appoint a

representative is a beneficiary, then only the beneficiary or the beneficiary’s legal guardian may sign.

If the party making the appointment is the provider or supplier, the provider or supplier (or person

authorized to act on behalf of the provider or supplier) must sign the form and complete this section.

The date the party signs the form must be included.

3. Completing Section II – “Acceptance of Appointment”- A specific individual must be named to act

as representative in the first line of this section; a party may not appoint an organization or group to

act as representative. The name of the individual appointed as representative must always be

completed, and his/her relationship to the party entered. The individual being appointed signs the

form with a signature, dates and completes the rest of this section.

4. Completing Section III – “Waiver of Fee for Representation”- This section must be completed when

the beneficiary is appointing a provider or supplier as representative, and the provider or supplier

being appointed has furnished the items or services that are the subject of the appeal.

5. Completing Section IV – “Waiver of Payment for Items or Services at Issue” – This section must be

completed when the beneficiary is appointing a provider or supplier who furnished the items or

services that are the subject of the appeal and the appeal involves issues described in §1879(a)(2) of

the Act (limitation on liability).

If any of the required elements listed above are missing from the appointment, or are determined to be

invalid (e.g., the signatures do not meet the requirements of this section), the appointment is considered

defective. See §270.1.6 for additional information on processing appeals with an incomplete or invalid

appointment.

Prohibition Against Charging a Fee for Representation

A provider or supplier that furnished items or services to a beneficiary may represent that beneficiary on the

beneficiary’s claim or appeal involving those items or services. However, the provider or supplier may not

charge the beneficiary a fee for representation in this situation. Further, the provider or supplier

representative being appointed as representative must waive any fee for such representation. The provider or

supplier representative does this by completing section III of the CMS-1696. Alternatively, the provider or

supplier must include a statement to this effect on any other conforming written instrument being used, and

must sign and date the statement.

Waiver of Right to Payment for the Items or Services at Issue

For beneficiary appeals involving a liability determination under §1879 of the Act where the provider or

supplier that furnished the items or services at issue is also serving as the beneficiary’s representative, the

provider or supplier must waive, in writing, any right to payment from the beneficiary for the items or

services at issue (including coinsurance and deductibles). The provider or supplier representative does this

by completing section IV of the CMS-1696 or other conforming written instrument, and must sign and date

the statement.

The prohibition against charging a fee for representation, and the waiver of right to payment from the

beneficiary for the items or services at issue, do not apply in those situations in which the provider or

supplier merely submits the appeal request on behalf of the beneficiary or at the beneficiary’s request (i.e.,

where the provider or supplier is not also acting as representative for the beneficiary), or where the items or

services at issue were not provided by the provider or supplier when the provider or supplier has been

appointed as the beneficiary’s representative.

B. Required Elements for Written Request (if not using the CMS-1696 form)

As set forth in 42 CFR 405.910(c), a written request for an appointment of representation must:

1. Be in writing and be signed and dated by both the party and the individual agreeing to be the

representative;

2. Provide a statement appointing the representative to act on behalf of the party, and authorizing the

adjudicator to release identifiable health information to the appointed representative;

3. Include a written explanation of the purpose and scope of the representation;

4. Contain both the party’s and appointed representative’s name, phone number, and address;

5. Contain a unique identifier of the party being represented. If the party being represented is the

beneficiary, the Medicare number must be provided. If the party being represented is a provider or

supplier, the National Provider Identifier number must be provided. (Exception: An applicable plan

appointing a representative in an appeal under 42 CFR §405.924(b)(16) is not required to include a

unique identifier) ;

6. Include the appointed representative’s professional status or relationship to the party; and

7. Be filed with the entity processing the party’s initial determination or appeal.

Providers or suppliers that are representing a beneficiary and that furnished the items or services at issue

must complete a “Waiver of Fee for Representation”. In addition, if the appeal involves a liability

determination under §1879 of the Act, the provider or supplier must also complete a “Waiver of Payment for

Items or Services at Issue”. See §270.1.2.A.4 and 5.

C. Revoking an Appointment

The party appointing a representative may revoke the appointment at any time by providing a written

statement of revocation to the contractor.