Your Right to Representation
To appoint a representative, you or your representative should complete the form below, entitled: Appointment of Representative CMS-1696.CMS-1696_v508Fillable
If you do not use form CMS-1696, your appointment must:
- Be in writing and signed and dated by you and your representative;
- Provide a statement appointing the representative to act on your behalf;
- Authorize the release of your personal health information to your representative;
- Include a written explanation of the purpose and scope of the representation;
- List your name and your representative’s names, phone numbers, and addresses;
- Include your Medicare Number (Health Insurance Claim Number or Medicare Beneficiary Identifier) or National Provider Identifier (NPI);
- Indicate your representative’s professional status, if any, or relationship to you; and
- Be filed with the entity processing your appeal.
Unless revoked, an appointment is considered valid for one year from the date the form is signed. Once the form is filed, it is valid for the duration of the appeal. Therefore, a signed form can be used for more than one appeal as long as the appeal is filed within one year of the date on the form.
In addition, there are certain individuals who can bring an appeal on your behalf, pursuant to State or other applicable laws. Such an individual, known as an “authorized representative,” may be a court-appointed guardian, an individual who has durable power of attorney, a health care proxy, or a person designated under a State’s health care consent statute.