Medicare Appointment of Representative Form (CMS-1696): How to Use It
Reviewed October 3, 2026. Form CMS-1696, the Appointment of Representative form, lets you give another person, such as a family member, friend, advocate, attorney or doctor, legal permission to act for you in a Medicare claim, appeal, grievance or request. Both you and your representative sign it, and you send it to the same place you send your appeal. An appointment is valid for one year from the date you both sign, and it stays in effect for the whole appeal it was filed with.
Quick answer: Download Form CMS-1696 from CMS, fill in your details and your representative’s details, both sign and date it, and attach it to your appeal or send it to the office handling your claim. Your representative can then make requests, present evidence, get information and receive all communication about the case.
What Form CMS-1696 is used for
Medicare.gov describes the form as a way of “giving another person legal permission to help you file an appeal” (Medicare.gov appeals forms). The form itself says that once appointed, the representative becomes “the main contact” with authority to make requests, present evidence, get information and receive all communication (Form CMS-1696).
People commonly use it when:
- An adult child is helping a parent appeal a denied claim or a coverage decision
- A spouse or friend handles paperwork for someone who is ill or has a disability
- A legal aid advocate, attorney or non-attorney representative takes on an appeal
- A doctor’s office or supplier represents a patient in an appeal (fee rules differ for providers and suppliers)
Who can be your representative
Almost anyone you trust can serve, including a relative, friend, advocate, attorney, financial advisor or health care provider. If someone already has legal authority to act for you under state law, such as a court-appointed guardian or a person holding a durable power of attorney for health care, they generally don’t need Form CMS-1696 but should send a copy of the legal document with the appeal. If someone only needs to talk to Medicare about your account, an authorization to disclose your personal health information is a separate, simpler step; it doesn’t let them file appeals for you.
How to fill out Form CMS-1696, section by section
| Section | What you fill in | Who signs |
|---|---|---|
| Section 1: Appointment | Your name, address, phone and Medicare number (or “not applicable” if you don’t have one), plus the representative’s name | You (the person appointing) |
| Section 2: Acceptance | The representative’s name, address, phone, relationship to you and professional status if any | The representative |
| Section 3: Waiver of fee | Used by a representative who agrees not to charge you a fee for the representation | The representative, if waiving a fee |
| Section 4: Waiver of payment | Used by a provider or supplier representative who agrees not to collect payment from you for the items or services at issue in the appeal | The provider or supplier, if applicable |
Section details are based on the current Form CMS-1696 (OMB No. 0938-0950, expiring 12/31/2028). Use the current version from CMS rather than an old copy.
Step-by-step
- Download the form from CMS (a large-print version is also available).
- Complete Section 1 with your information and your Medicare number exactly as it appears on your card.
- Have your representative complete and sign Section 2.
- Complete Sections 3 and 4 only if they apply.
- Make sure both of you date the form. The one-year period runs from the date it’s signed by both.
- Attach the form to your appeal request or send it to the contractor, plan or office handling your claim, appeal, grievance or request. Keep a copy.
How long an appointment lasts
According to the form, an appointment of representative is valid for one year from the date it’s signed by both parties. Once the form is filed with a particular claim, appeal, grievance or request, the representation stays valid for the duration of that matter unless you revoke it. For a new, unrelated appeal after the year has passed, you’ll need a new form.
Representative fees
A representative who wants to charge you must get the fee approved when the case involves a hearing before an Administrative Law Judge or a review by the Medicare Appeals Council (the representative files form OMHA-118 for that). The form lists exceptions, for example when the person being represented is a provider or supplier. Free help is often available from your State Health Insurance Assistance Program.
Where CMS-1696 fits in the Medicare appeals process
Original Medicare has five levels of appeal, and Medicare.gov lists a form for most of them (Medicare.gov):
| Appeal level | Who decides | Form you can use |
|---|---|---|
| 1. Redetermination | Medicare Administrative Contractor | CMS-20027 |
| 2. Reconsideration | Qualified Independent Contractor | CMS-20033 |
| 3. Hearing | Administrative Law Judge (OMHA) | OMHA-100 |
| 4. Review | Medicare Appeals Council | Written request |
| 5. Judicial review | Federal district court | Court filing |
Your representative’s appointment is filed with the appeal at whatever level you start. Medicare Advantage and Part D plans have their own appeal steps (organization determinations, coverage determinations and reconsiderations), and plans accept CMS-1696 as well; see CMS managed care notices and forms. Common reasons to appeal include a denied claim, a drug that isn’t covered by your plan’s formulary, or equipment denied under rules like Medicare’s same or similar policy for DME.
Tips to avoid delays
- Send the form with the appeal itself, not separately, so the reviewer sees it immediately.
- Double-check the Medicare number, names and both signatures; an unsigned form can make the appointment invalid.
- If you change representatives, file a new form and notify the office handling your case.
- Keep your contact details current with Social Security and Medicare; see how to change your address with Social Security.
- Have your Medicare number handy. If you can’t find it, see how to find your Medicare number.
If you’re helping someone who has Medicare because of a disability, our guide to Medicare for people under 65 with disabilities explains their coverage, and Medicare coordination of benefits can help sort out which insurer should pay a disputed claim.
Frequently asked questions
What is Form CMS-1696?
It’s Medicare’s Appointment of Representative form. It lets you name someone to act for you in a Medicare claim, appeal, grievance or request.
How long is a CMS-1696 valid?
One year from the date both you and your representative sign it. Once filed with a specific appeal, it remains valid for that entire appeal unless revoked.
Where do I send the Appointment of Representative form?
Send it to the same place you send your claim, appeal, grievance or request, ideally attached to the appeal itself.
Does my representative need to be a lawyer?
No. A family member, friend, advocate or other trusted person can be your representative.
Is CMS-1696 the same as a power of attorney?
No. CMS-1696 covers representation in Medicare matters only. A durable power of attorney for health care or a legal guardianship under state law is broader, and those representatives can generally act by submitting their legal documents.
Can I use CMS-1696 for a Medicare Advantage or Part D appeal?
Yes. Medicare Advantage and Part D plans accept the Appointment of Representative form for appeals and grievances.
This article is general information, not legal, tax or individual insurance advice. Medicare365 is not affiliated with or endorsed by the U.S. government or the federal Medicare program.