Get Cms 1696 2018-2024

Section III on the front of this form can be used for that purpose. In some instances as indicated on the form the fee must be waived for representation. Approval of Fee The requirement for the approval of fees ensures that a representative will receive fair value for the services performed before DHHS on behalf of a beneficiary and provides the beneficiary with a measure of security that the fees are determined to be reasonable. Liability under 1879 a 2 of the Act is at issue. Form CMS-1696 11/15 Charging of Fees for Representing Beneficiaries before the Secretary of DHHS An attorney or other representative for a beneficiary who wishes to charge a fee for services rendered in connection with an appeal before the Secretary of DHHS i.e. an Administrative Law Judge ALJ hearing Medicare Appeals Council review or a proceeding before an ALJ or the Medicare Appeals Council as a result of a remand from federal district court is required to obtain approval of the fee in accordance with 42 CFR 405. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Form Approved OMB No. 0938-0950 APPOINTMENT OF REPRESENTATIVE Name of Party Medicare Number beneficiary as party or National Provider Identifier Number provider as party Section 1 Appointment of Representative To be completed by the party seeking representation i.e. the Medicare beneficiary the provider or the supplier I appoint this individual to act as my representative in connection with my claim or asserted right under Title XVIII of the Social Security Act the Act and related provisions of Title XI of the Act. 910 f. The form Petition to Obtain Representative Fee elicits the information required for a fee petition. It should be completed by the representative and filed with the request for ALJ hearing or request for Medicare Appeals Council review. Approval of a representative s fee is not required if 1 the appellant being represented is a provider or supplier 2 the fee is for services rendered in an official capacity such as that of legal guardian committee or similar court appointed representative and the court has approved the fee in question 3 the fee is for representation of a beneficiary in a proceeding in federal district court or 4 the fee is for representation of a beneficiary in a redetermination or reconsideration. If the representative wishes to waive a fee he or she may do so. In approving a requested fee the ALJ or Medicare Appeals Council will consider the nature and type of services rendered the complexity of the case the level of skill and competence required in rendition of the services the amount of time spent on the case the results achieved the level of administrative review to which the representative carried the appeal and the amount of the fee requested by the representative. Conflict of Interest Sections 203 205 and 207 of Title XVIII of the United States Code make it a criminal offense for certain officers employees and former officers and employees of the United States to render certain services in matters affecting the Government or to aid or assist in the prosecution of claims against the United States. Individuals with a conflict of interest are excluded from being Where to Send This Form Send this form to the same location where you are sending or have already sent your appeal if you are filing an appeal grievance if you are filing a grievance initial determination or decision if you are requesting an initial determination or decision. If additional help is needed contact your Medicare plan or 1-800-MEDICARE 1-800-633-4227.