Get the free Appointment of Representative Form (CMS Form -1696)
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS
FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 09380950APPOINTMENT OF REPRESENTATIVE
Name of Party Medicare Number (beneficiary as party) or
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How to fill out appointment of representative form
How to fill out appointment of representative form
01
To fill out an appointment of representative form, follow these steps:
02
Obtain the appointment of representative form from the respective institution or organization.
03
Read the instructions and guidelines provided on the form carefully.
04
Fill out the personal information section, including your full name, contact details, and address.
05
Provide the necessary details of the representative you are appointing, such as their name, contact information, and relationship to you.
06
Clearly state the purpose or reason for appointing the representative.
07
Sign and date the form at the designated spaces.
08
Review the completed form to ensure all the information is accurate and complete.
09
Make a copy of the appointment of representative form for your records.
10
Submit the form to the relevant institution or organization either in person or by mail as instructed.
Who needs appointment of representative form?
01
The appointment of representative form is typically needed by individuals who require someone else to act on their behalf in a specific situation or matter. This could apply to various situations, including legal matters, healthcare decisions, financial transactions, or any other situation where a representative is required for legal or administrative purposes. It is best to consult the specific institution or organization to determine if you need to fill out an appointment of representative form.
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