CMS Pub. 100-04, ch. 30, § 450.3.6

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

Type Of Representative

Appointed Representative

Authorized Representative

An appointed representative is an individual

designated by a beneficiary to act on the

beneficiary’s behalf. A beneficiary may

designate an appointed representative via the

“Appointment of Representative” form CMS-

1696 (or a similar written instrument

containing the required elements under 42

CFR 405.910). 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:

• If a beneficiary is temporarily incapacitated and there is no appointed or

authorized 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 MCSN. 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. There should be no relevant conflict

between the representative’s and the beneficiary’s interests.

• 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 MCSN 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 MCSN must be delivered to a representative who is not physically present, the

hospital is not required to personally deliver the MCSN or have the MCSN delivered via

courier to the representative. The hospital must complete the MCSN as required and may

telephone the representative instead, and then also mail the MCSN. The date and time of

the telephone call is considered the receipt date of the MCSN.

The hospital must complete all of the following actions under this delivery method:

1. Verbally convey all contents of the MCSN.

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

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

communicated verbally to the representative.

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 MCSN to the representative the day telephone

contact is made.

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.