Get Fiscal Intermediary Authorization Application. Fi Authorization Application

Filling out the Fiscal Intermediary Authorization Application is a crucial step for those seeking authorization from the New York State Department of Health. This guide will provide you with clear, step-by-step instructions to help you complete the application accurately and efficiently.

Follow the steps to complete the application effectively.

1. Use the ‘Get Form’ button to obtain the Fiscal Intermediary Authorization Application and open it in the available editor.
2. Begin by entering your identifying data. Fill in the name and address of the Fiscal Intermediary entity, its Employer Identification Number, and the name of the operator. If applicable, use 'same' if the names and addresses are identical.
3. Provide the contact information for a person who can supply additional information regarding the application and check the ownership type box.
4. If your organization is a corporation, attach a board resolution authorizing the application and indicate the attachment number in the appropriate section.
5. In the project narrative section, check the purpose of your application and provide a brief description. If your description exceeds 200 words, include it as a separate attachment.
6. Outline your Fiscal Intermediary history and overview by describing your organization’s services and plans for involving consumers in feedback processes.
7. Complete the establishment information section by selecting the structure of your application. Attach required documents based on the structure chosen, such as partnership agreements, certificates, or incorporation documents.
8. If relevant, provide the personal identifying information for individuals in positions of authority within your organization.
9. Make sure to answer all questions regarding any legal actions or affiliations from the past ten years. Provide documentation where necessary.
10. Finally, ensure that you sign and notarize the application before submission. Save your changes, review the completed application, and prepare it for electronic submission to the designated email.

Complete your application today to ensure timely processing of your authorization.