Section 1: Person appointing
Name, Medicare Number or National Provider Identifier, mailing address, phone number, optional email and fax, signature and date signed.
CMS-1696
APPOINTMENT OF REPRESENTATIVE
- Agency
- CMS
- Revision
- 2026-10-01
- Fillable fields
- 40
- Pages
- 2
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-1696: Appointment of Representative
Form CMS-1696 is the Appointment of Representative form from the Centers for Medicare & Medicaid Services. The form says it is used to appoint a representative to act on your behalf for a claim, appeal, grievance or request. By signing, the person appointing agrees that the representative will be the main contact, with authority to make requests, present evidence, get information and receive all communication about the action. The form notes the representative may see personal medical information.
Section 1 is completed by the patient, provider or other person appointing a representative, and Section 2 by the representative. Sections 3 and 4 are waivers the representative completes if they apply: a waiver of fee for representation and, for providers and suppliers, a waiver of payment for the items or services at issue. Page 2 covers how long the appointment lasts, where to send the form and the rules on charging fees.
The CMS page says the form was revised with minor non-substantive changes and approved by the Office of Management and Budget on 10/1/2026. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-1696
Section 2: Representative
Representative name, professional status or relationship, mailing address, phone number, optional email and fax, and a signature and date under a certification about eligibility to act as a representative.
Section 3: Waiver of fee
A signature waiving the right to charge and collect a fee for representing the person in Section 1 before the Secretary of HHS.
Section 4: Waiver of payment
For a provider or supplier representing a patient they furnished items or services to, a signature waiving the right to collect payment from the patient if a liability determination under section 1879(a)(2) of the Act is made.
Instructions and fee rules
Page 2 explains how long the appointment is valid, where to send the form, when a representative's fee needs approval, and what OMHA or the Medicare Appeals Council considers when approving a fee.
Conflict of interest
The form says individuals with a conflict of interest are excluded from serving as representatives of patients before HHS, citing sections 203, 205 and 207 of Title XVIII of the United States Code.
The form says all fields in Sections 1 and 2 are required unless marked optional.
How to fill out Form CMS-1696
- 1
Complete and sign Section 1
The person appointing the representative enters their name, Medicare Number or NPI (or not applicable), mailing address and phone, then signs and dates it.
- 2
Have the representative complete Section 2
The representative adds their details and relationship, then signs to agree to act as a representative and to the certification.
- 3
Add the waivers that apply
The instructions say Section 3 is required when a representative is required or has agreed to waive a fee, and Section 4 when a provider or supplier represents the patient and liability under section 1879(a)(2) is at issue.
- 4
Check the fee rules
A representative charging a fee for an appeal before the Secretary of HHS completes form OMHA-118 and files it with the request for ALJ hearing, OMHA review or Medicare Appeals Council review, according to the form.
- 5
Send it where your coverage says
Original Medicare: the address on your Medicare Summary Notice. Medicare Advantage or a drug plan: the form says to contact the plan's member services to find out where to send it.
Why fill Form CMS-1696 on indox
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- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes, how long it lasts and help
Original Medicare
Send the form to the address on your Medicare Summary Notice (MSN). If you no longer have the MSN, the form says to call 1-800-MEDICARE (1-800-633-4227) to get the address.
Medicare Advantage and drug plans
The form says to contact member services at your plan to find out where to send it. The number is on your Evidence of Coverage or Member ID card.
Not to CMS
The form says not to send it directly to CMS. The CMS address in the Paperwork Reduction Act notice is for comments on the form.
How long it lasts
The form says an appointment is valid for one year from the date it is signed by both the person appointing and the representative, and can be used for other appeals or actions during that year. Unless revoked, it lasts for the duration of the claim, appeal, grievance or request it was filed for.
Help and other formats
Contact your Medicare plan or call 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. The form says Medicare information is available in large print, braille or audio. The CMS page also lists a Spanish version.
Time to complete
The form estimates 15 minutes per notice.
Related forms
CMS-10106
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CMS-20027
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CMS-20033
MEDICARE RECONSIDERATION REQUEST FORM
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CMS-20031
TRANSFER (ASSIGNMENT) OF APPEAL RIGHTS
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CMS-1490S
PATIENT'S REQUEST FOR MEDICAL PAYMENT (English/Spanish)
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Who uses Form CMS-1696?
The form is signed by two people: the one appointing a representative and the representative.
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Questions about Form CMS-1696
How long is a CMS-1696 appointment valid?
The form says one year from the date it is signed by both the person appointing and the representative. Unless revoked, the representation lasts for the duration of the claim, appeal, grievance or request it was filed for.
Where do I send Form CMS-1696?
With Original Medicare, the form says to send it to the address on your Medicare Summary Notice. With a Medicare Advantage or prescription drug plan, it says to contact the plan's member services. It says not to send it directly to CMS.
Can one form be used for more than one appeal?
The form says a completed form can be used for other appeals or actions during the one-year period it is valid.
Can a provider or supplier be the representative?
Yes. The form says a provider or supplier who furnished the items or services at issue may represent the patient but may not charge the beneficiary a fee for it, and signs Section 3 to waive the fee.
Does a representative's fee need approval?
The form says a fee for an appeal before the Secretary of HHS is approved under 42 CFR 405.910(f) using form OMHA-118. It lists exceptions, including a provider or supplier appellant and a fee for a redetermination or reconsideration.
What if there is no Medicare number or NPI?
The instructions say that if the person or entity appointing a representative doesn't have a Medicare number or National Provider Identifier, fill in not applicable.
Is Form CMS-1696 available in Spanish?
Yes. The CMS page lists a Spanish version of the form, plus HTML versions in English and Spanish.