Understanding the Appointment of Representative (AOR) Form: What Every Dental Practice Should Know

If your dental practice ever handles Medicare or Medicaid appeals, you’ve likely come across the CMS-1696 Appointment of Representative (AOR) form.

This form gives someone — usually a biller, consultant, or attorney — the legal authority to act on a patient’s behalf during a claim, appeal, grievance, or request with the Centers for Medicare & Medicaid Services (CMS).

In simple terms, the AOR form allows you to speak for the patient when navigating claim denials, submitting appeals, or requesting information from CMS.

What the CMS-1696 Form Does

The AOR form officially appoints a representative to:

• Make requests and present evidence

• Access claim information

• Receive all correspondence from CMS

• Discuss personal medical and claim details directly

Once the form is accepted, CMS recognizes the representative as the primary contact for that claim or appeal.

Enter your email below for a copy of Form CMS-1696 AOR. 

Key Details Every Dental Office Should Know

🗓 1. The AOR Form Is Valid for One Year

Once signed by both the patient (or beneficiary) and the representative, the appointment stays active for one year.
If the same issue continues or multiple appeals are filed within that year, the same form can be reused — no need to fill it out again.

📑 2. Sections That Must Be Completed

• Section 1: Information about the person appointing the representative (the patient or beneficiary)

• Section 2: Information about the representative (provider, staff member, consultant, or attorney)

These two sections must be filled out completely for CMS to process the form.

💸 3. Waivers and Fees

Section 3: Waiver of Fee for Representation
If you’re a provider or supplier involved in the case, you cannot charge a fee to represent the patient. You’ll need to sign this section confirming the waiver.

Section 4: Waiver of Payment for Items or Services
This applies when the appeal involves non-coverage determinations (under §1879(a)(2) of the Social Security Act). Providers who delivered the service must confirm whether they are waiving payment if CMS rules against coverage.

💡 If you’re an attorney or consultant charging a fee at the higher appeal levels (like an ALJ or OMHA hearing), you’ll also need CMS Form OMHA-118 for fee approval.

📬 4. Where to Send the Form

The AOR should be sent to the same address as the appeal or claim submission.
If you’re appealing a Medicare Administrative Contractor (MAC) decision, send it to the MAC’s listed appeals address.

🚫 5. Who Cannot Be a Representative

Anyone with a conflict of interest (for example, someone financially benefiting from the outcome) cannot serve as a patient representative.

Why This Matters for Dental Practices

Dental offices handling Medicare Advantage or medical cross-coding claims can use the AOR form to:

• Allow a trusted team member or consultant to communicate directly with CMS

• Streamline the appeals process when coverage is denied

• Protect patient privacy while ensuring timely follow-up on claim resolutions

Having this form on file prevents CMS from rejecting your communications for “lack of authorization.”

Related Articles

Related