Appointment of Representative Form for Medicare & Medicaid Services
This file allows the appointment of a representative to act on behalf of a beneficiary in connection with Medicare and Medicaid services. It includes sections for the appointment, acceptance, waiver of fees, and more. The form ensures proper representation and fee approval.
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How do I fill this out?
To fill out the Appointment of Representative Form, start by providing the beneficiary’s details in Section I. Follow up by getting the appointed representative to complete Section II. If applicable, complete Section III and IV for fee waivers.
How to fill out the Appointment of Representative Form for Medicare & Medicaid Services?
1
Enter the beneficiary’s details in Section I.
2
Appointed representative completes Section II.
3
Complete Section III if the representative waives the fee.
4
Complete Section IV if there is a waiver of payment for items or services.
5
Sign and date the form before submission.
Who needs the Appointment of Representative Form for Medicare & Medicaid Services?
1
Beneficiaries of Medicare or Medicaid who need representation.
2
Representatives appointed to act on behalf of a beneficiary.
3
Health providers and suppliers needing to complete a waiver of payment.
4
Attorneys or legal representatives looking to charge a fee for services.
5
Individuals needing authorization for fee approval from DHHS.
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What are the instructions for submitting this form?
To submit this form, ensure all sections are completed and signed. Send the form to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. You may also submit via fax or through an online submission form if available on the CMS website. Always keep a copy of the completed form for your records.
What are the important dates for this form in 2024 and 2025?
The form may need to be updated periodically. Please refer to the latest updates for any changes in 2024 and 2025.
What is the purpose of this form?
The purpose of this form is to allow a Medicare or Medicaid beneficiary to appoint a representative to act on their behalf. This can include making requests, presenting evidence, and receiving notices related to appeals. Additionally, the form covers the acceptance of the appointment and any applicable waivers related to fees or payments.
Tell me about this form and its components and fields line-by-line.
- 1. Beneficiary Details: Includes name, Medicare number, signature, date, and contact information of the beneficiary.
- 2. Representative Acceptance: To be filled out by the representative including their acceptance, professional status, signature, and date.
- 3. Waiver of Fee for Representation: Optional section where the representative can waive their fee for representation.
- 4. Waiver of Payment for Items or Services: To be completed by providers or suppliers if applicable, waiving the right to collect payment for specific items or services.
What happens if I fail to submit this form?
Failure to submit this form may result in the beneficiary not having a designated representative for their Medicare or Medicaid appeals.
- Lack of Representation: The beneficiary may not have someone authorized to act on their behalf.
- Delay in Appeals Process: Not submitting the form can delay the appeals process.
- Inability to Waive Fees: Providers or suppliers may not be able to waive fees without this form.
How do I know when to use this form?
- 1. Appointing a Representative: When the beneficiary needs someone to act on their behalf.
- 2. Legal Representation: When an attorney is representing the beneficiary.
- 3. Requesting Fee Waivers: When the representative or provider needs to waive fees.
- 4. Medicare Appeals: For any appeals process requiring representation.
- 5. Payment Disputes: When there are disputes regarding payments for items or services.
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Is it possible to waive fees using this form?
Yes, Sections III and IV of the form allow for fee waivers.
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