MCFI Representative Payee Forms

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Document NameSummaryTags
Rep Payee Start-up PacketThis packet includes all the forms an applicant needs for Representative Payee.
Form SSA-4164 Fiscal AgentAdvance Notification of Representative Payment. This form should be completed when the Social Security Administration assigns a representative payee to manage your benefits.
Physicians-Statement-Form SSA-787
Fiscal Agent
Physician's/Medical Officer's Statement of Patient's Capability to Manage Benefits. This form must be completed to receive Social Security or Supplemental Security Income payments.
Rep Payee Informed Consent for Release
of Information
Informed Consent for Release of Information. This form authorizes MCFI to give information to Representative Payee Services if necessary.
Rep Payee Private Pay Service Agreement. This form is to authorize Representative Payee services are not responsible for payments not covered by private insurance or other payment sources.
RP Client Set-up Form MCFIRep Payee Client Set-up Form. This form is to for getting client information.
RP Addition to Client Set-up FormThis form is for providing billing information so that the payee can manage the payments on behalf of the beneficiaries.