FI Cease Operations: FI to MCO/LDSS

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Date:

From: <Fiscal Intermediary Name>

RE: Fiscal Intermediary Termination of Services Notification to <MCO or LDSS> Dear <MCO or LDSS>,

This letter is to inform you that effective <Month, Day, Year>, <name of FI> will no longer be providing Fiscal Intermediary (FI) services <if limited to service area indicate the area that you will no longer be serving> to the following list of consumers under the Consumer Directed Personal Assistance Program (CDPAP).

You will also be receiving a copy of the notifications we sent to each CDPAP member listed below

CDPAP Consumer Name	CDPAP Consumer Medicaid CIN Number

In addition, please note we have similarly notified the personal assistants of each CDPAP member listed above, and the Department of Health that we will no longer be providing FI services as of the date indicated above.

If you have any questions, you may contact us at <xxxx> Sincerely,

<FI NAME>

Cc: New York State Department of Health at ConsumerDirected@health.ny.gov