FISCAL AGENT REQUEST FORM (FARF): Fill out & sign online

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Click ‘Get Form’ to open the FISCAL AGENT REQUEST FORM (FARF) in the editor.
Begin by filling out the 'Services Facilitator/Agency Information' section. Enter your agency name, NPI number, and contact details for the services facilitator.
Next, specify the referral date and effective date. Choose the appropriate referral type/service request from the dropdown menu.
Indicate whether the individual is new to consumer-directed services by selecting 'Yes' or 'No'. If applicable, provide details about prior employers and transitions.
In the 'Consumer Information' section, enter personal details such as first name, last name, date of birth, Medicaid ID number, and contact information.
Complete the 'Employer of Record Information' section if necessary. Indicate if the consumer will be their own employer and provide relevant contact details if not.
Finally, review all entries for accuracy before submitting. You can email or fax your completed form as instructed at the top of the document.

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See more FISCAL AGENT REQUEST FORM (FARF) versions

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (71 Votes)
2019	4.1 Satisfied (52 Votes)

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