OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Appointment of Representative (Provider Supplier)

IC 185564 under ICR 201804-0938-026 · OMB 0938-0950.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Appointment of Representative (Provider Supplier)
 
No Modified
 
Voluntary
 
42 CFR 405.910

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-1696 Nombramiento de un Representante Clean_2015_CMS_1696_version508_Spanish112515.docx Yes No Fillable Fileable
Form and Instruction CMS-1696 Appointment of Representative (English) Form 1696version508_2017MEAG_Final.pdf Yes No Fillable Fileable

Health Health Care Services

 

347,284 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 312,556 0 0 -54,100 0 366,656
Annual IC Time Burden (Hours) 78,139 0 0 -13,525 0 91,664
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.