View Information Collection (IC)

View Information Collection (IC)

IC Title:	Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Beneficiary)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 405.910

Information Collection Instruments:

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

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40,740	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 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	40,740	0	0	0	0	40,740
Annual IC Time Burden (Hours)	10,185	0	0	0	0	10,185
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
Crosswalk	Crosswalk_CMS1696 Spanish.xlsx	12/01/2015
Track Changes	Redline_2015_CMS_1696_version508_Spanish112515.docx	12/01/2015

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