Fillable Appointment of Representative CMS-1696


(4.7 / 5) 59 votes
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Get your Appointment of Representative CMS-1696 in 3 easy steps

  • 01 Fill and edit template
  • 02 Sign it online
  • 03 Export or print immediately

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.

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Fillable online Appointment of Representative CMS-1696
(4.7 / 5) 59 votes
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