Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (CMS-1696)

Forms and Documents

Document Name	Status
Form CMS-1696 Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Beneficiary) Form and Instruction	Modified
Form CMS-1696 Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Provider Supplier) Form and Instruction	Modified
CMS-1696 - Supporting Statement A [rev 5-18-2015 by OSORA PRA].docx Supporting Statement A	2015-12-01
Justification [12-01-2015 OSORA PRA].docx Justification for No Material/Nonsubstantive Change	2015-12-01

IC Document Collections

IC ID	Document Title	Status
8804	Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Beneficiary) Form and Instruction	Modified
185564	Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Provider Supplier) Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0950	ICR Reference No: 201512-0938-001
Status: Historical Active	Previous ICR Reference No: 201507-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (CMS-1696)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/11/2016
	Date Received in OIRA: 12/01/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2018	06/30/2018	06/30/2018
Responses	407,396	0	407,396
Time Burden (Hours)	101,849	0	101,849
Cost Burden (Dollars)	0	0	0

---

Abstract: This form will be completed by beneficiaries, providers and suppliers who wish to appoint representatives to assist them with obtaining initial determinations and filing appeals. The appointment of representative form must be signed by the party making the appointment and the individual agreeing to accept the appointment.

---

Authorizing Statute(s): PL: Pub.L. 106 - 554 521 Name of Law: Medicare, Medicaid, and SCHIP Benefits Improvement Act of 2000 (BIPA)
   PL: Pub.L. 108 - 178 931 Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
   US Code: 18 USC 1869 Name of Law: BIPA
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 10686	02/26/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 26568	05/08/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Beneficiary)	CMS-1696	Nombramiento de un Representante
Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Provider Supplier)	CMS-1696	Nombramiento de un Representante

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	407,396	407,396	0	0	0	0
Annual Time Burden (Hours)	101,849	101,849	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/01/2015

---