View Information Collection Request (ICR) Package
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Brief and OIRA conclusion
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Burden
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Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-0950
ICR Reference No:
201507-0938-010
Status:
Historical Active
Previous ICR Reference No:
201505-0938-007
Agency/Subagency:
HHS/CMS
Agency Tracking No:
Title:
Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (CMS-1696)
Type of Information Collection:
No material or nonsubstantive change to a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
11/06/2015
Retrieve Notice of Action (NOA)
Date Received in OIRA:
07/17/2015
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
06/30/2018
06/30/2018
06/30/2018
Responses
407,396
0
407,305
Time Burden (Hours)
101,849
0
101,849
Cost Burden (Dollars)
0
0
0
Abstract:
This form will be completed by beneficiaries, providers and suppliers who wish to appoint representatives to assist them with obtaining initial determinations and filing appeals. The appointment of representative form must be signed by the party making the appointment and the individual agreeing to accept the appointment.
Authorizing Statute(s):
PL:
Pub.L. 106 - 554 521
Name of Law: Medicare, Medicaid, and SCHIP Benefits Improvement Act of 2000 (BIPA)
PL:
Pub.L. 108 - 178 931
Name of Law: Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA)
US Code:
18 USC 1869
Name of Law: BIPA
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
80 FR 10686
02/26/2015
30-day Notice:
Federal Register Citation:
Citation Date:
80 FR 26568
05/08/2015
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
2
IC Title
Form No.
Form Name
Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Beneficiary)
CMS-1696
Nombramiento de un Representante
Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (Provider Supplier)
CMS-1696
Nombramiento de un Representante
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
407,396
407,305
0
91
0
0
Annual Time Burden (Hours)
101,849
101,849
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$0
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Mitch Bryman 410 786-5258 Mitch.Bryman@cms.hhs.gov
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
07/17/2015
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