Printable blank Appointment of Representative CMS-1696

Fill Out Form
  • Edit
  • Fill out
  • Sign
  • Export

1. What is CMS-1696 form?

CMS-1696 form can be found online and consists of two pages that will help you to choose a person who will eventually become your representative. The form is used all around the country.

2. What I need CMS-1696 form for?

You should use CMS-1696 form when you want to:

  • Appoint any person you know (friend, child, attorney, or any other) to act on your behalf.

When the signed form is valid, your representative will be able to:

  • Handle various Medicare payments and other claims.
  • Choose Medicare coverage.

If you do not use CMS-1696 form, the appointment should be signed by the representative and you. You will have to specify that you want your representative to act on your behalf.     Do not forget to mention your name, and the name of your representative.

3. How to fill out CMS-1696 form?

Specify your name, address where you live, ZIP code, State, and phone number. You also have to specify the same information about the person you want to become your representative. The document should be signed by the enrollee and by the representative.

It is important for the representative to accept the appointment. Otherwise, the document will not be valid, which can delay the whole process of appointment. At the bottom of the form, you can see some additional information. For example, you can get to know where to send the form. Note that people with conflict of interests cannot be representatives.

4. Organizations that work with CMS-1696 form?

  • U.S. Centers for Medicare & Medicaid Services.

Hear What PDFLiner Users Have to Say & Join Them Today

  • Fred Walters
    Entrepreneur
    Now that I’ve switched from Word to PDFLiner, I save lots of time processing and digitally distributing tons of billing forms, work orders, forecast reports, and invoices. In addition to this, thanks to PDFLiner, we’ve significantly minimized our paper consumption. Excellent tool that helps me cope with my business workflow faster and easier.
  • Peter Scheffel
    Self-employed attorney
    PDFLiner allows me to streamline the processes of generating and managing legal documents, as well as collecting electronic signatures for all my contracts and agreements. I like that I can customize forms on the go and access PDFLiner from all my gadgets. No more printing or scanning! That’s just brilliant!
  • Lisa Matthews
    University student
    When you’re a student, you deal with PDFs a lot… Newsletters, various worksheets, official forms you need to fill in and sign, etc… To me, filling out a PDF form used to be among the trickiest and most time-consuming things ever. But then a friend of mine introduced me to PDFLiner, and oh my God, my life has changed since then. It’s easy to use and has so many great features. Just awesome, I love it!
Please, wait...
We use unpersonalized cookies to keep our site working and collect statistics for marketing purposes. By continuing to use this site, you consent to this policy. Learn more
Accept