CMS Pub. 100-04, ch. 30, § 200.3.7

The IM may be delivered to a beneficiary’s appointed or authorized representative.

Types of Representative

Appointed Representative Authorized Representative

Appointed representatives are individuals

designated by beneficiaries to act on their

behalf. A beneficiary may designate an

appointed representative via the

“Appointment of Representative” form, the

CMS-1696. See Chapter 29 of the Medicare

Claims Processing Manual, section 270.1,

for more information on appointed

representatives.

An authorized representative is an

individual who, under State or other

applicable law, may make health care

decisions on a beneficiary’s behalf (e.g.,

the beneficiary’s legal guardian, or

someone appointed in accordance with

a properly executed durable medical

power of attorney).

Notes:

• However, if a beneficiary is temporarily incapacitated and there is no

representative, a person (typically, a family member or close friend) whom the

hospital has determined could reasonably represent the beneficiary, but who has

not been named in any legally binding document, may be a representative for the

purpose of receiving the IM. Such a representative should act in the beneficiary’s

best interests and in a manner that is protective of the beneficiary and the

beneficiary’s rights. Therefore, a representative should have no relevant conflict

of interest with the beneficiary.

• In instances where the notice is delivered to a representative who has not been

named in a legally binding document, the hospital must annotate the IM with the

name of the staff person initiating the contact, the name of the person contacted,

and the date, time, and method (in person or telephone) of the contact.

Delivery to off-site representatives

If the IM must be delivered to a representative who is not physically present, the hospital

is not required to personally deliver the IM or have the IM delivered via courier to the

representative. The hospital must complete the IM as required and may instead telephone

the representativeand then mail the IM. The date and time of the telephone call is

considered the receipt date of the IM.

The hospital must complete all of the following actions.

1. Verbally convey all contents of the IM;

2. Note the date and time this information is communicated verbally;

3. Annotate the “Additional Information” section to reflect that IM was

communicated verbally to the representative; and

4. Annotate the “Additional Information” section with the name of the staff person

initiating the contact, the name of the representative contacted by phone, the date

and time of the telephone contact, and the telephone number called.

5. Mail a copy of the annotated IM to the representative the day telephone contact is

made.

A hard copy of the IM must be sent to the representative by certified mail, return receipt

requested, or any other delivery method that can provide signed verification of delivery

(e.g., FedEx, UPS). The burden is on the hospital to demonstrate that timely contact was

attempted with the representative and that the notice was delivered.

If the hospital and the representative both agree, the hospital may send the notice by fax

or e-mail; however, the hospital or CAH’s fax and e-mail systems must meet the Health

Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security

requirements.