Appoint a Representative

You may appoint someone to act on your behalf and serve as your representative on an appeal. You and your representative must sign the Appointment of Representative Form CMS 1696 and must be included with your appeal. The appointment is valid for one year unless revoked. A copy of this form must be included with any future appeals.
If you become incapacitated or of a legally incompetent status, a surrogate may be authorized by the court to act in accordance with State law to file an appeal on your behalf. In this case, an Appointment of Representative Form does not need to be executed. Instead, your surrogate must produce other appropriate legal papers supporting his or her status as your authorized representative when submitted an appeal on your behalf.