Appointment of Representative Form Instructions
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 |
Last Updated Dec 09 , 2023
