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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 appointment of representativetufts health

01
Obtain the appointment of representative form from Tufts Health.
02
Fill out the form with the required information such as patient's details, representative's details, and reason for appointment.
03
Sign and date the form.
04
Submit the completed form to Tufts Health as per their instructions.

Who needs appointment of representativetufts health?

01
Patients who are unable to make medical decisions for themselves due to incapacitation or other reasons may need to appoint a representative with Tufts Health.
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Appointment of representativetufts health is a legal document that allows an individual to act on behalf of the patient in making healthcare decisions.
Any patient who wishes to designate a representative to make healthcare decisions on their behalf must file an appointment of representativetufts health.
To fill out appointment of representativetufts health, the patient must provide information about their chosen representative and sign the document in the presence of witnesses.
The purpose of appointment of representativetufts health is to ensure that the patient's healthcare wishes are carried out in the event that they are unable to communicate their preferences.
The appointment of representativetufts health must include the representative's name, contact information, relationship to the patient, and specific instructions regarding healthcare decisions.
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