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 Feb 26, 2018