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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICESForm CMS1696 Approved OMB No. 09380950APPOINTMENT OF REPRESENTATIVE Name of Party Medicare Number (beneficiary as party)
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How to fill out cms-1696 appointment of representative
How to fill out cms-1696 appointment of representative
01
Obtain the CMS-1696 form, which is called Appointment of Representative.
02
Fill in the patient's personal information, such as name, address, and Medicare number.
03
Indicate the reason for appointing a representative and provide details about the representative.
04
Include any additional information or documentation that may support the appointment.
05
Sign and date the form.
06
Submit the completed form to the appropriate Medicare administrative body.
Who needs cms-1696 appointment of representative?
01
Any Medicare beneficiary who wishes to designate a representative to act on their behalf in matters related to Medicare.
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What is cms-1696 appointment of representative?
The cms-1696 appointment of representative is a form used by Medicare beneficiaries to appoint someone to represent them in matters relating to Medicare.
Who is required to file cms-1696 appointment of representative?
Medicare beneficiaries who wish to appoint a representative to act on their behalf in Medicare-related matters are required to file cms-1696.
How to fill out cms-1696 appointment of representative?
To fill out cms-1696 appointment of representative, the beneficiary must provide their personal information, the representative's information, and sign and date the form.
What is the purpose of cms-1696 appointment of representative?
The purpose of cms-1696 appointment of representative is to authorize someone to act on the beneficiary's behalf in dealings with Medicare.
What information must be reported on cms-1696 appointment of representative?
The cms-1696 form requires the beneficiary's identifying information, the representative's identifying information, and a description of the scope of the representative's authority.
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