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OMB Control No: 0938-0950	ICR Reference No: 202508-0938-005
Status: Received in OIRA	Previous ICR Reference No: 202406-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: Appointment of Representative and Supporting Regulations in 42 CFR 405.910 (CMS-1696)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 08/05/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2025
Responses	208,173	213,208
Time Burden (Hours)	52,043	53,302
Cost Burden (Dollars)	0	0

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	208,173	213,208	-5,035
Annual Time Burden (Hours)	52,043	53,302	-1,259
Annual Cost Burden (Dollars)	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden is computed based on relevant available data for Medicare appeals, and those figures are updated annually. Current appeals data for 2024 indicates that the number of first level appeals has decreased since 2023. While the total time to complete the form has not changed, the hourly burden estimates have decreased and is being adjusted in this iteration for all respondents due to a fewer number of appeals being filed. Overall, the number of appeals using this collection has decreased by 5,035 (prior amount 213,208 minus current amount 208,173) which translates to a decrease of 1,259 burden hours (prior amount 53,302 minus current amount 52,043).

Annual Cost to Federal Government: $1,425

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. 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? No

Agency Contact: Stephan McKenzie 410 786-1943 stephan.mckenzie@cms.hhs.gov