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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICESForm CMS1696 Approved OMB No. 09380950APPOINTMENT OF REPRESENTATIVE Name of PartyMedicare Number (beneficiary as party)
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How to fill out i authorize this individual
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Start by writing the date at the top of the form.
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Fill in your full name in the designated space on the form.
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Provide the full name of the individual you are authorizing in the appropriate section.
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Write down the reason for authorizing the individual and specify the actions they are allowed to take.
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Sign and date the form at the bottom to confirm your authorization.
Who needs i authorize this individual?
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Anyone who wants to give someone else the legal authority to act on their behalf in a specific situation may need to fill out an 'I authorize this individual' form.
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What is i authorize this individual?
I authorize this individual is a declaration used to grant another person the authority to act on your behalf in specific matters, such as tax or legal transactions.
Who is required to file i authorize this individual?
Individuals or entities that wish to delegate authority to another person to represent them in matters requiring official action require the filing of this authorization.
How to fill out i authorize this individual?
To fill out this form, provide your personal information, the details of the individual being authorized, the scope of the authorization, and any additional required information according to the relevant guidelines.
What is the purpose of i authorize this individual?
The purpose is to legally allow someone else to act on your behalf, whether it involves financial decisions, legal matters, or other official tasks.
What information must be reported on i authorize this individual?
The information that must be reported includes your identity, the identity of the authorized individual, the specific authorities granted, and any relevant dates.
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