Information Collection List

IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.	Form Name
Appointment of Representative (Beneficiary)	Modified	34728	8682	0	Form and Instruction	CMS-1696	Appointment of Representative (English)
Appointment of Representative (Beneficiary)	Modified	34728	8682	0	Form and Instruction	CMS-1696	Nombramiento de un Representante
Appointment of Representative (Provider Supplier)	Modified	312556	78139	0	Form and Instruction	CMS-1696	Appointment of Representative (English)
Appointment of Representative (Provider Supplier)	Modified	312556	78139	0	Form and Instruction	CMS-1696	Nombramiento de un Representante
Total burden requested under this ICR:		347284	86821	0
To view an IC, click on IC Title