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FISCAL INTERMEDIARY CHOICE NAME OF FACILITY: ADDRESS: CITY, STATE, ZIP CODE: In order that the Social Security Administration may be advised of your intermediary preference, please indicate the organization
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How to fill out fiscal intermediary choice:

01
Start by gathering all the necessary information for filling out the form. This may include personal details, financial information, and any relevant documentation.
02
Carefully read through the instructions provided on the form. Ensure that you understand each section and what information is required.
03
Begin by providing your personal information, such as your name, address, contact details, and social security number. Double-check for any errors or typos.
04
Proceed to the section where you need to select a fiscal intermediary. This is an important decision as the fiscal intermediary will handle financial matters on your behalf. Research and consider different options that align with your needs and preferences.
05
Once you have chosen a fiscal intermediary, provide their name, contact information, and any other required details.
06
Some forms may require additional information or documentation, such as proof of income or medical records. Make sure to include these as per the instructions.
07
Review all the information you have provided on the form. Verify that everything is accurate, complete, and legible.
08
Sign and date the form as required. If there are any additional signatories, ensure they also complete the necessary sections.
09
Make a copy of the filled-out form and any supporting documents for your records.
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Submit the form through the designated method, whether it be online, through mail, or in person. Ensure that you adhere to any deadlines or submission requirements.

Who needs fiscal intermediary choice?

01
Individuals who require assistance with financial matters related to their healthcare or other services may need to make a fiscal intermediary choice.
02
This could include individuals with disabilities who receive government benefits, elderly individuals who need help managing their finances, or individuals in need of financial support for specific services.
03
The need for a fiscal intermediary may vary based on individual circumstances and the specific program or service being utilized. It is important to assess whether having a fiscal intermediary is necessary or beneficial in each particular situation.

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