Form · Medicare
CMS-1696 form (Medicare appointment of representative)
What it is, who uses it, and field-by-field help. Publisher: CMS. Links checked October 23, 2026.
Quick answer
Form CMS-1696 (OMB 0938-0950) appoints a representative to act for a person on a Medicare claim, appeal, grievance, or request. It is valid for one year from when both people sign, and it goes to the address on the Medicare Summary Notice or to the plan, not to CMS.
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At a glance
- Form
- CMS-1696, Appointment of Representative
- OMB number
- 0938-0950
- Valid for
- One year from the date both parties sign
- Send to
- Original Medicare: the address on your MSN. A plan: your plan's member services. Not CMS.
- Rule
- 42 CFR 405.910
- Get the form
- CMS-1696 (PDF)
Who uses it
- Medicare patients naming a relative, attorney, or other person to act for them
- Providers and suppliers representing a patient in an appeal (they cannot charge a fee for it)
Sections
- Section 1. Person appointing
- Name, Medicare number or NPI, address, phone, and signature of the patient, provider, or other person appointing. Write "not applicable" if there is no Medicare number or NPI.
- Section 2. Representative
- The representative's name, relationship or professional status, contact details, and signature agreeing to act.
- Section 3. Waiver of fee
- Signed by providers and suppliers who furnished the items at issue, and by any representative waiving a fee.
- Section 4. Waiver of payment
- Signed by a provider representing the patient when liability under section 1879(a)(2) is at issue.
Related pages
Questions
How long does a CMS-1696 last?
One year from the date both people sign. It can be used for other appeals in that year, and it stays valid for the life of the appeal it was filed with unless revoked.
Where do I send the CMS-1696?
Original Medicare: the address on the Medicare Summary Notice. Medicare Advantage or Part D: your plan's member services. Do not send it to CMS.
Government sources
- PDFCMS-1696 (PDF)
- Regulation42 CFR 405.910