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Appointment of Representative (Beneficiary)
 
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 Appointment of Representative (English) Appointment of Representative form_CMS 1696 English_clean2021.pdf Yes No Printable Only

Health Health Care Services

 

27,054 0
   
Individuals or Households
 
   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 27,054 0 0 -7,674 0 34,728
Annual IC Time Burden (Hours) 6,764 0 0 -1,918 0 8,682
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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