Submit Form - AOR 27 EN

Form Approved
Department of Health and Human Services OMB No. 0938-0950
Centers for Medicare & Medicaid Services Expires: 08/31/2025
B Appointment of Representative 1
Use this form to appoint a representative to act on your behalf for your claim, appeal, grievance or request. By signing
this form and appointing this representative, you agree that the representative will be the main contact and have
authority to make requests, present evidence, get information, and receive all communication about your action. This
person may see your personal medical information. All fields in Sections 1 and 2 are required unless marked optional.
Section 1: Information about the person appointing the representative
This section must be completed by the patient, provider or other person appointing a representative.

Name *

Please provide a valid Name.

Medicare Number or National Provider Identifier *

Please provide a valid Medicare Number or National Provider Identifier.

Mailing address *

Please provide a valid Mailing address.

Phone number (with area code) *

Please provide a valid Phone number (with area code) (e.g., 123-456-7890).

City *

Please provide a valid City.

State *

Please provide a valid State.

ZIP code *

Please provide a valid ZIP code.

Email (optional)

Please provide a valid Email (optional).

Fax (optional)

Please provide a valid Fax (optional).

Signature *

Please sign Signature.

Date signed (mm/dd/yyyy) *

Please provide a valid Date signed (mm/dd/yyyy).

Section 2: Information about the representative
This section must be completed by the representative.

Representative name *

Please provide a valid Representative name.

Professional status or relationship to the person in Sectio *

Please provide a valid Professional status or relationship to the person in Sectio.

Mailing address *

Please provide a valid Mailing address.

Phone number (with area code) *

Please provide a valid Phone number (with area code) (e.g., 123-456-7890).

City *

Please provide a valid City.

State *

Please provide a valid State.

ZIP code *

Please provide a valid ZIP code.

Email (optional)

Please provide a valid Email (optional).

Fax (optional)

Please provide a valid Fax (optional).

By signing below, you agree to act as a representative and certify that you haven’t been disqualified, suspended, or
prohibited from practice before the Department of Health and Human Services (HHS) or otherwise disqualified from
acting as a representative. Any fee to be charged for acting as a representative may be subject to review and approval
by the Secretary. If you’re charging a fee, go to instructions on page 2.

Signature *

Please sign Signature.

Date signed (mm/dd/yyyy) *

Please provide a valid Date signed (mm/dd/yyyy).

Representative must complete the sections below, if applicable (go to instructions on page 2)
Section 3: Waiver of fee for representation
Providers and suppliers who furnished the items or services at issue can’t charge a fee for representation and must sign
below to waive their fee. Representatives who choose to waive their fee for representation must also sign below.
I waive my right to charge and collect a fee for representing the person in Section 1 before the Secretary of HHS.

Signature

Please sign Signature.

Date signed (mm/dd/yyyy)

Please provide a valid Date signed (mm/dd/yyyy).

Section 4: Waiver of payment for items or services at issue
If you’re a provider or supplier and you furnished items or services to the patient you’re representing, if the appeal
involves a question of whether you or the patient didn’t know, or couldn’t reasonably be expected to know, that
Medicare wouldn’t cover the items or services.
I waive my right to collect payment from the patient for the items or services at issue in this appeal if a determination
of liability under §1879(a)(2) of the Act is made.

Signature

Please sign Signature.

Date signed (mm/dd/yyyy)

Please provide a valid Date signed (mm/dd/yyyy).

Form CMS-1696 (09/24) 1