Get Va Cdcn Fiscal Agent Request Form 2019-2025

Completing the VA CDCN Fiscal Agent Request Form online is an important step for service facilitators to enroll a new consumer or employer. This guide provides clear instructions to ensure that you fill out the form accurately and completely.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the form and open it for editing.
2. Begin by filling in the Employer Enrollment Packet section. Specify whether you would like CDCN to mail a blank packet to the employer or if the service facilitator will print it from CDCN’s website.
3. Next, complete the Services Facilitator Agency Information section. Provide the agency name, NPI number, email address, and contact number. Be sure to mark any relevant options.
4. Move on to the Consumer Information section. Fill in all mandatory fields denoted by an asterisk. This includes the full name, date of birth, Social Security number, Medicaid ID number, email address, telephone number, and physical and mailing addresses.
5. In the Employer of Record Information subsection, choose an option regarding the employer designation. Ensure that you input all required information, including the first name, middle name, last name, Social Security number, email address, telephone number, and physical and mailing addresses.
6. After filling out all relevant sections, review the information for accuracy. Ensure that required fields are completed, and all names match official documents.
7. Finally, save your changes, download, print, or share the completed form as needed. If assistance is required, refer to the contact information provided on the form.

Complete your documents online today to ensure a smooth enrollment process.