Medicare Sign Up pack sample

( ) - Form SSA-1696-U6 (03-2011) ef (03-2011) Destroy Prior Editions Social Security Administration Form Approved OMB No. 0960-0527 Please read the instructions before completing this form. Name (Claimant) (Print or Type) Social Security Number - - Wage Earner (If Different) Social Security Number - - Part I APPOINTMENT OF REPRESENTATIVE I appoint this person, (Name and Address) to act as my representative in connection with my claim(s) or asserted right(s) under: Title II (RSDI) Title XVI (SSI) Title XVIII (Medicare Coverage) Title VIII (SVB) This person may, entirely in my place, make any request or give any notice; give or draw out evidence or information; get information; and receive any notice in connection with my pending claim(s) or asserted right(s). I authorize the Social Security Administration to release information about my pending claim(s) or asserted right(s) to designated associates who perform administrative duties (e.g. clerks), partners, and/or parties under contractual arrangements (e.g. copying services) for or with my representative. I appoint, or I now have, more than one representative. My main representative is (Name of Principal Representative) Signature (Claimant) Address Telephone Number (with Area Code) Fax Number (with Area Code) ( ( ) - Date Part II ACCEPTANCE OF APPOINTMENT I, , hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration; that I am not disqualified from representing the claimant as a current or former officer or employee of the United States; and that I will not charge or collect any fee for the representation, even if a third party will pay the fee, unless it has been approved in accordance with the laws and rules referred to on the reverse side of the representative's copy of this form. If I decide not to charge or collect a fee for the representation, I will notify the Social Security Administration. (Completion of Part III satisfies this requirement.) Check one: I am an attorney. I am a non-attorney eligible for direct payment under SSA law. I am a non-attorney not eligible for direct payment. I am now or have previously been disbarred or suspended from a court or bar to which I was previously admitted to practice as an attorney. YES NO I am now or have previously been disqualified from participating in or appearing before a Federal program or agency. YES NO I declare under penalty of perjury that I have examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge. Signature (Representative) Address Telephone Number (with Area Code) ( ) - Fax Number (with Area Code) ) - Date Part III FEE ARRANGEMENT (Select an option, sign and date this section.) Charging a fee and requesting direct payment of the fee from withheld past-due benefits. (SSA must authorize the fee unless a regulatory exception applies.) Charging a fee but waiving direct payment of the fee from withheld past-due benefits --I do not qualify for or do not request direct payment. (SSA must authorize the fee unless a regulatory exception applies.) Waiving fees and expenses from the claimant and any auxiliary beneficiaries --By checking this block I certify that my fee will be paid by a third-party, and that the claimant and any auxiliary beneficiaries are free of all liability, directly or indirectly, in whole or in part, to pay any fee or expenses to me or anyone as a result of their claim(s) or asserted right(s). (SSA does not need to authorize the fee if a third-party entity or a government agency will pay from its funds the fee and any expenses for this appointment. Do not check this block if a third-party individual will pay the fee.) Waiving fees from any source --I am waiving my right to charge and collect any fee, under sections 206 and 1631(d)(2) of the Social Security Act. I release my client and any auxiliary beneficiaries from any obligations, contractual or otherwise, which may be owed to me for services provided in connection with their claim(s) or asserted right(s). Signature (Representative) Date FILE COPY sample