Follow the steps to fill out the VA CDCN Fiscal Agent Request Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the 'Services Facilitator/Agency Information' section. Enter the agency name, agency NPI number, services facilitator name, phone number, and email address.
3. Provide the 'Referral Date' and 'Effective Date.' Be sure to include the correct dates to avoid processing delays.
4. In the 'Referral Type/Service Request' section, select the appropriate option for the agency authorizing services. Indicate whether the individual is new to consumer-directed services and provide details if applicable.
5. Complete the 'Consumer Information' section by filling in the first name, last name, date of birth, Medicaid ID number, social security number, telephone number, email address, and physical address including street, city, state, and zip code.
6. Address the 'Employer of Record Information.' Indicate if the consumer will be the employer of record. If not, please provide the first name, last name, telephone number, and email address of the actual employer of record.
7. For the enrollment/transition packet submission, note that the employer of record is encouraged to submit an electronic Enrollment or Transition Packet via DocuSign. If a hard copy is required, check the box and provide the recipient's name and mailing address.
8. Review all information entered for accuracy and completeness. Ensure all necessary documents accompany the request when submitting.
9. Once satisfied with your entries, save the changes. You may download, print, or share the form as needed to ensure timely submission.

Complete your VA CDCN Fiscal Agent Request Form online today to ensure a smooth processing experience.