TX HHS Form 3696. Expression of Intermediary Preference

The TX HHS Form 3696, Expression of Intermediary Preference, is a crucial document that helps ensure the Social Security Administration has accurate information about your preferred intermediary for your facility. This form should be used to identify the organization you have selected as your intermediary.

This form requires you to write your selection in the space provided at the bottom of the page and sign it before returning it as soon as possible. The document 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.

This form is essential for individuals who need to specify their intermediary preference for their facility. By completing Form 3696, you can ensure that your preferences are accurately recorded by the Social Security Administration.