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Cms 1696

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Department of Health and Human Services Centers for Medicare & Medicaid Services

Form Approved OMB No. 0938-0950

 Appp oint  Ap oi ntmen mentt ooff Repr Re pres esent entati ativv e Name of Party

Medicare or National Provider Identifier Number

Section Se ction 1: Appoint ment of Re Representa presentative tive To be completed by t he party seeking representation (i.e. (i.e.,, the Medicare Medicare beneficiary, the provid er or the supp lier): I appoint this individual, to act as my representative in connection with my claim or asserted right under title XVIII of the Social Security Act (the “Act”) and related provisions of title XI of the Act. I authorize

this individual with to make any request; or toI understand elicit evidence; obtain appeals information and to receive any notice in connection my appeal, whollytoinpresent my stead. that to personal medical information; information; related to my appeal may be disclosed to the representative indicated indicated below. Signature of Party Seeking Representation

Date

Street Address

Phone Number (with Area Code)

City

State

Zip Code

Section Se ction 2: Accepta Acceptance nce of Appoin tment To be completed by t he representative: I, , hereby accept the above appointment. I certify that I have not been disqualified, suspended,, or prohibited from practice before the department of Health and Human Services; that I am not, as a current or suspended former employee of the United States, disqualified from acting as the party’s representative; and that I recognize that any fee may be subject to review and approval by the Secretary.

I am a / an (Professional status or relationship to the party, e.g. attorney, relative, etc.) Signature of Representative

Date

Street Address

Phone Number (with Area Code)

City

State

Zip Code

Secti Se ction on 3: Waiver of Fee for Representation Representation   Instruct ions: This secti on must be comp leted if the representative representative is required to, or chooses to waive their fee for representation. (Note that providers or suppliers that are representing a beneficiary and furnished the items or services may not charge a fee for representation and must  complete this section.) I waive my right to charge and collect a fee for representing before the Secretary of the Department of Health and Human Services. Signature

Date

Section 4: Waiver of Payment for Items or Services at Issue Instructions: Providers or suppliers serving as a representative for a beneficiary to whom they provided items or services mus t compl ete this section if t he appeal appeal invol ves a question of li ability un der section 1879(a 1879(a)( )(2) 2) of the Act. (Section 1879(a)(2) generally addresses whether whether a provider/supplier provider/supplier or beneficiary did not know, or could not reasonably be expected to know, that the items or services at issue would not be covered by Medicare.) I waive my right to collect payment from the beneficiary for the items or services at issue in this appeal if a determination of

liability under §1879(a)(2) of the Act is at issue. Signature Form CMS-1696 (Rev 06/12)

Date

 

  Charging of Fees Fees fo r Representing Beneficiaries Befor e the Secretary Secretary of the Department Department o f Health and Human Services

 An attorney, or other other representative for a beneficiary, beneficiary, who wishes wishes to charge charge a fee for services rendered in connection connection with an appeal before the Secretary of the Department of Health and Human Services (DHHS) (i.e., an Administrative Law Judge (ALJ) hearing, Medicare Appeals Council review, or a proceeding before an ALJ or the Medicare Appeals Council as a result of a remand from federal district court) is required to obtain approval of the fee in accordance with 42 CFR §405.910(f). The form, “Petition to Obtain Representative Fee” elicits the information required for a fee petition. It should be completed by the representative and filed with the request for ALJ hearing or request for Medicare Appeals Council review.  Approval of a representative’s representative’s fee is not required if: (1) the appellant appellant being represe represented nted is a provider or supplier; supplier; (2) the fee is for services rendered in an official capacity such as that of legal guardian, committee, or similar court appointed representative representative and the court has approved the fee in question; (3) the fee is for representation of a beneficiary in a proceeding in federal district court; or (4) the fee is for representation of a beneficiary in a redetermination or reconsideration. If the representative wishes to waive a fee, he or she may do so. Section III on the front of this form can be used for that purpose. In some instances, as indicated on the form, the fee must be waived for representation representation  Auth  Au thor or izat ion io n o f Fee

The requirement for the approval of fees ensures that a representative will receive fair value for the services performed before DHHS on behalf of a beneficiary, and provides the beneficiary with a measure of security that the fees are determined to be reasonable. In approving a requested fee, the ALJ or Medicare Appeals Council will consider the nature and type of the complexity theresults case, the level ofthe skilllevel and of competence required in to rendition of the services, theservices amountrendered, of time spent on the case,ofthe achieved, administrative review which the representative carried the appeal and the amount of the fee requested by the representative. Conflict of Interest

Sections 203, 205 and 207 of title XVIII of the United States Code make it a criminal offense for certain officers, employees and former officers and employees of the United States to render certain services in matters affecting the Government or to aid or assist in the prosecution of claims against the United States. Individuals Individuals with a conflict of interest are excluded from being representatives of beneficiaries before DHHS. Where to Send This Form

Send this form to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision. If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1-800-633-4227). (1-800-633-4227).

 According to the Paperwork Reduction Reduction Act of 1995, no no persons are required to respond to a collection collection of informatioonn unless it displays a valid OMB control numb number. er. The valid OMB control number collection is 0938-0950. Thecomments time required to prepare distribute thistime collection is 15 per notice, including timeplease to select thetopreprinted form, completeforit this and information deliver it to the beneficiary. If you h ave concerning the and accuracy of the estimates orminutes suggestions for improving thisthe form, write CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Baltimore, Maryland 21244-1850.

Form CMS-1696 (Rev 06/12)

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