Appointment Of Representative Form. Web form approved omb no. Centers for medicare & medicaid services (cms) issue date:
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Web form approved omb no. 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: Web who is this for? He or she must give his or her name,. Review and complete all required sections. If you are appointing multiple representatives, use separate forms for each representative. You can appoint a spouse, family member, friend, lawyer or. Web back to cms forms list; You may list one or.
Make sure you have your medicare number. Web who is this for? Web how to complete this form section 1: You may list one or. 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. Appointment of representative to be completed by the party seeking representation (i.e., the medicare beneficiary, the provider or the supplier): You can name more than one. If you do, you may want to complete a. If you are appointing multiple representatives, use separate forms for each representative. Give the name and address of the person you’re appointing. He or she must give his or her name,.
