Intermediary Preference
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Intermediary Preference Form. This is a California form and can be use in Department Of Health And Human Services Statewide.
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Tags: Intermediary Preference, HS 413, California Statewide, Department Of Health And Human Services
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)
HS 413 (2/05)
_______________________
(Date)
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