Appointing a Representative 

The CMS Appointment of Representative Form (CMS Form-1696) is a way for you to name someone who can make decisions on your behalf. This could be anything from filing a Medicare complaint or appeal, all the way up to more critical situations like signing an advance directive.

1.    If you have a Medicare number, make sure to print or type it and your name on the top of the form.

2.    You can appoint one person or more than one to act as your representative depending on what works best for you.

3.    You must be able to designate individual people as your representatives and cannot appoint organizations or law firms in their place. This person will need complete Acceptance of Appointment form that states they are accepting this role.

4.    After accepting the appointment, this person should complete a Waiver of Fee for Representation that states they will not charge you for acting on their behalf.

updated 1.14.22