Form representative 2026

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4.2 out of 5

53 votes

The document is a form from the Department of Health and Human Services, specifically for appointing a representative to act on behalf of a Medicare beneficiary in connection with claims or appeals under the Social Security Act. It includes sections for the appointment, acceptance, waiver of fees, and authorization of fees for representation. The form outlines the responsibilities and requirements for both the party seeking representation and the appointed representative, including conditions under which fees may be charged or waived.

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How to use or fill out the Appointment of Representative form

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Click ‘Get Form’ to open it in the editor.
In Section I, enter your name and Medicare or National Provider Identifier Number. Appoint your representative by filling in their name and providing your signature along with the date, address, and phone number.
Move to Section II where your representative must accept the appointment. They should fill in their name, professional status, and provide their signature and date.
If applicable, complete Section III to waive any fees for representation. The representative must sign and date this section.
Finally, if relevant, fill out Section IV regarding the waiver of payment for items or services at issue. Ensure all signatures are provided before submission.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (81 Votes)
2015	4.4 Satisfied (160 Votes)
2012	4.3 Satisfied (70 Votes)
2011	4.2 Satisfied (53 Votes)
2010	4.7 Satisfied (65 Votes)
2005	4.4 Satisfied (64 Votes)