MCFI Representative Payee Forms
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| Document Name | Summary | Tags |
|---|---|---|
| Rep Payee Start-up Packet (Spanish) | This packet includes all the forms an applicant needs for Representative Payee. | |
| Form SSA-4164 Fiscal Agent | Advance 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 MCFI | Rep Payee Client Set-up Form. This form is to for getting client information. | |
| RP Addition to Client Set-up Form | This form is for providing billing information so that the payee can manage the payments on behalf of the beneficiaries. |