Appointment of Representative Form CMS-1696 | Centers for Medicare & Medicaid Services

The page could not be loaded. The CMS.gov Web site currently does not fully support browsers with “JavaScript” disabled. Please enable “JavaScript” and revisit this page or proceed with browsing CMS.gov with “JavaScript” disabled. Instructions for enabling “JavaScript” can be found here. Please note that if you choose to continue without enabling “JavaScript” certain functionalities on this website may not be available.

Skip to Main Content

Form #: CMS 1696
Form Title: APPOINTMENT OF REPRESENTATIVE
Revision Date: 06/01/2012
O.M.B. #: 0938-0950
O.M.B. Expiration Date: 06/30/2015
CMS Manual: N/A
Special Instructions: N/A

Downloads

A federal government website managed by the Centers for Medicare & Medicaid Services
7500 Security Boulevard, Baltimore, MD 21244

Centers for Medicare & Medicaid Services

7500 Security Boulevard

Baltimore, MD21244

USA

CMS Forms

Downloads

CMS & HHS Websites

Tools

Helpful Links