Form DHCS9113 Download Printable PDF or Fill Online Appointment of
Appointment Of Representative Form. Web form approved omb no. Web how to complete this form section 1:
Form DHCS9113 Download Printable PDF or Fill Online Appointment of
Title ii title xvi title xviii title viii This document is cms form 1696 appointment of representative. You can appoint a spouse, family member, friend, lawyer or. Make sure you have your medicare number. If you do, you may want to complete a. Appoint at least one person to act on your behalf. Cms 1696 dynamic list information. Web back to cms forms list; You can use our electronic version of the form by asking your representative to start an online submission where you both can complete your appointment electronically without personal contact. Review and complete all required sections.
Give the name and address of the person you’re appointing. Title ii title xvi title xviii title viii Give the name and address of the person you’re appointing. Web back to cms forms list; Print or type your number and your name on the top of the form. Appointment of representative to be completed by the party seeking representation (i.e., the medicare beneficiary, the provider or the supplier): You can use our electronic version of the form by asking your representative to start an online submission where you both can complete your appointment electronically without personal contact. Centers for medicare & medicaid services (cms) issue date: Claimant representatives can now complete most sections of the electronic notice of. Cms 1696 dynamic list information. Appoint at least one person to act on your behalf.
