Charging of Fees for Representing Beneficiaries Before the Secretary of the Department of Health and Human
An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection with
an appeal before the Secretary of the Department of Health and Human Services (DHHS) (i.e., an Administrative Law
Judge (ALJ) hearing, Medicare Appeals Council review, or a proceeding before an ALJ or the Medicare Appeals Council as
a result of a remand from federal district court) is required to obtain approval of the fee in accordance with 42 CFR
The form, “Petition to Obtain Representative Fee” elicits the information required for a fee petition. It should be completed
by the representative and filed with the request for ALJ hearing or request for Medicare Appeals Council review.
Approval of a representative’s fee is not required if: (1) the appellant being represented is a provider or supplier;
(2) the fee is for services rendered in an official capacity such as that of legal guardian, committee, or similar court
appointed representative and the court has approved the fee in question; (3) the fee is for representation of a beneficiary in
a proceeding in federal district court; or (4) the fee is for representation of a beneficiary in a redetermination or
reconsideration. If the representative wishes to waive a fee, he or she may do so. Section III on the front of this form can be
used for that purpose. In some instances, as indicated on the form, the fee must be waived for representation
Authorization of Fee
The requirement for the approval of fees ensures that a representative will receive fair value for the services performed
before DHHS on behalf of a beneficiary, and provides the beneficiary with a measure of security that the fees are
determined to be reasonable. In approving a requested fee, the ALJ or Medicare Appeals Council will consider the nature
and type of services rendered, the complexity of the case, the level of skill and competence required in rendition of the
services, the amount of time spent on the case, the results achieved, the level of administrative review to which the
representative carried the appeal and the amount of the fee requested by the representative.
Conflict of Interest
Sections 203, 205 and 207 of title XVIII of the United States Code make it a criminal offense for certain officers, employees
and former officers and employees of the United States to render certain services in matters affecting the Government or to
aid or assist in the prosecution of claims against the United States. Individuals with a conflict of interest are excluded from
being representatives of beneficiaries before DHHS.
Where to Send This Form
Send this form to the same location where you are sending (or have already sent): (1) your appeal if you are filing an
appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial
determination or decision.
If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1-800-633-4227).
ording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-0950. The time required to prepare and distribute this collection is 15 minutes per notice, including the time to select the preprinted form,
complete it and deliver it to the beneficiary. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA
Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Form CMS-1696 (Rev 06/12)