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Intermediary Preference HS 413 - California
| Intermediary Preference Form. This is a California form and can be used in Licensing And Certification Department Of Health And Human Services Statewide . |
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State of California--Health and Human Services Agency Department of Health Services INTERMEDIARY PREFERENCE Note: This form is sent to new health facilities that may want to participate in the Medicare Program. The form accompanies the Medicare initial kit. Please reply to: Department of Health Services Licensing and Certification Program Centralized Applications Unit MS 3402 P.O. Box 997413 Sacramento, CA 95899-7413 RE: (Facility name) (Facility address--number, street) (City, state, ZIP code) In order to assure that the Social Security Administration has your intermediary preference on record, would you please identify the organization you have selected as intermediary for your facility? Please write your selection in the space provided at the bottom of this page. Be sure to sign this form and return it as soon as possible. ____________________________________________ (Intermediary choice) ____________________________________________________________ (Administrator's signature) _______________________ (Date) HS 413 (2/05) American LegalNet, Inc. www.FormsWorkflow.com
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