View the below instructions for completing the CMS Appointment of Representative form.
| Field |
Brief Description |
| Name of Party |
Name of represented party (beneficiary, provider or supplier) |
| Medicare Number (beneficiary as party) or National Provider Identifier Number (provider as party) |
Medicare ID or National Provider Identifier (NPI) |
Section 1
| Field |
Brief Description |
| Blank In Section 1 paragraph |
Name of representative appealing on behalf of party |
| Signature of Party Seeking Representation |
Hand written signature of party required (beneficiary, provider or supplier) |
| Date |
Must be within 30 days of appointed representative's signature - Valid for one year from oldest date signed |
| Street Address |
Provider's street address |
| Phone Number |
Provider's phone number (10 digit) |
| City |
Provider's city |
| State |
Provider's state |
| Zip Code |
Provider's zip code |
Section 2
| Field |
Brief Description |
| 1st Blank In Section 2 paragraph |
Name of representative appealing on behalf of party |
| 2nd Blank In Section 2 paragraph |
Relationship of individual to party |
| Signature of Representative |
Hand written signature of appointed representative required |
| Date |
Must be within 30 days of party's signature - Valid for one year from oldest date signed |
| Street Address |
Appointed representative's street address - Correspondence will be sent to this address |
| Phone Number |
Appointed representative's phone number (10 digit) |
| City |
Appointed representative's city - Correspondence will be sent to this address |
| State |
Appointed representative's state - Correspondence will be sent to this address |
| Zip Code |
Appointed representative's zip code - Correspondence will be sent to this address |
Section 3
| Field |
Brief Description |
| Blank In Section 3 paragraph |
Name of represented party (beneficiary, provider or supplier) |
| Signature |
Hand written signature of appointed representative |
| Date |
Date signed |
Section 4
| Field |
Brief Description |
| Signature |
Hand written signature of appointed representative - Only required if provider or supplier is also acting as beneficiary representative |
| Date |
Date signed |
