TX HHS Form 3696. Expression of Intermediary Preference

The TX HHS Form 3696, Expression of Intermediary Preference, helps ensure that the Social Security Administration has your preferred intermediary organization on record. This form is typically used in situations where you have selected an intermediary for your facility, and it's essential to identify this organization to avoid any potential issues.

This form requires you to write down your selection of intermediary organization in the provided space at the bottom of the page. It's crucial to sign this form and return it as soon as possible to ensure that your preference is recorded accurately. The form also includes a list of Texas providers, including TrailBlazer Health Enterprises LLC (formerly Blue Cross/Blue Shield of Texas) and Mutual of Omaha Insurance Medicare.

Key points to note include:

• Selecting an intermediary organization for your facility
• Filling out the form with your preferred intermediary's information