Quick Start

Type directly into the official fillable PDF.
Use Save / Download and the PDF viewer download icon to save a completed copy.
Use Open Saved Form later to retrieve that PDF.
Print when ready and follow the agency's submission instructions.

Works inside MedClaimSoftware

This resource uses a browser-compatible local copy of the government form, so it does not depend on the agency website allowing an embedded PDF.

What this form is for

Use this form to appoint a person to act on your behalf for a Medicare claim, appeal, grievance, or request.

Agency: Centers for Medicare & Medicaid Services

Your data stays local

MedClaimSoftware does not receive the information you type into the form. Save the completed PDF to a location you control.

Before submitting

CMS currently lists this form with OMB expiration December 31, 2028. Check the official CMS page for updates before submitting.

Check the current official instructions →

Current file

CMS-1696 — blank official form

Chrome or Microsoft Edge is recommended for fillable PDF fields, saving, and printing.

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