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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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What is provider or supplier as?
Provider or supplier as is a form that must be filed with certain information by healthcare providers or suppliers.
Who is required to file provider or supplier as?
Healthcare providers or suppliers are required to file provider or supplier as.
How to fill out provider or supplier as?
Provider or supplier as can be filled out online or on paper, following the instructions provided by the relevant authorities.
What is the purpose of provider or supplier as?
The purpose of provider or supplier as is to report relevant information about healthcare providers or suppliers to the appropriate regulatory bodies.
What information must be reported on provider or supplier as?
Provider or supplier as must include information such as name, address, contact details, services provided, and any other relevant information requested.
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