Positive Community Connections: Request to Direct Bill Fiscal Intermediary for Membership
By entering your information on this form, you acknowledge that you want Positive Community Connections (PCC) to arrange with your Fiscal Intermediary to pay PCC directly for your Individual membership. The funding line in your self-direction budget will be IDGS Memberships.

If you are not interested in direct billing through your Fiscal Intermediary, please complete your membership application and payment securely through our website at https://positivecc.org/membership
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Email *
Name *
Address *
Phone Number *
Who is your SD Broker? *
Enter SD Broker's phone number
SD Broker's phone extension (if applicable)
Enter SD Broker's email
Who is your Fiscal Intermediary (FI)? *
Who is your Primary Contact at your FI?
Enter FI Primary Contact phone number
FI Primary Contact's phone extension (if applicable)
Enter FI Primary Contact email
Certification: I give Positive Community Connections expressed permission to contact my SD Broker and Fiscal Intermediary to setup direct payment for my Individual membership to Positive Community Connections. *
Upon completion of this form, a PCC representative will begin the process of setting up direct payment. When we receive approval from the Fiscal Intermediary, your membership will be activated and you will receive a welcome package, member id and benefits information.  If you have any additional questions, please note them below.
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