Appointment Of Representative Form. Print or type your number and your name on the top of the form. He or she must give his or her name,.
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Web back to cms forms list; You can name more than one. Review and complete all required sections. Title ii title xvi title xviii title viii This document is cms form 1696 appointment of representative. You can appoint a spouse, family member, friend, lawyer or. If you are appointing multiple representatives, use separate forms for each representative. He or she must give his or her name,. Print or type your number and your name on the top of the form. You may list one or.
You can use our electronic version of the form by asking your representative to start an online submission where you both can complete your appointment electronically without personal contact. He or she must give his or her name,. Your representative fills out this section. Make sure you have your medicare number. Print or type your number and your name on the top of the form. Review and complete all required sections. If you do, you may want to complete a. If you are appointing multiple representatives, use separate forms for each representative. Web who is this for? Claimant representatives can now complete most sections of the electronic notice of. Web form approved omb no.
