Vendor Forms

BELOW WE ARE PROVIDING A LIST OF UP-TO-DATE FORMS FOR VENDORS WITH EXISTING CONTRACTS IN THE CHILDREN’S SYSTEM OF CARE.

9000 Code Reimbursement Forms

This form is used when a vendor spends their own money on a client and it is approved for reimbursement through a planned action. These forms were last updated on 5.21.19

9000 Code Reimbursement Form – Fillable [PDF]

9000 Code Reimbursement Form – Example [PDF]

9000 Code Process Map [PDF]

Contract Forms

Schedule 3.2: Agreement by Designated Personnel [PDF] Individual workers must sign this as proof of their knowledge of duties and responsibilities when providing service within the system of care.

Vendor Service Code Manual [PDF] This is the up-to-date listing of what we currently offer to Erie County’s Children’s System of Care within High Fidelity Wraparound Care Coordination. It will give you a description of the service, qualifications necessary to provide this service, and reimbursement fees categorized by vendor code.

New Vendor Agency Application [PDF] This form is to be used to apply to become a Vendor Agency within High Fidelity Wraparound Erie County.

Add Non-Clinical Codes Form [PDF] This form is to be used by Vendor Agencies who would like to add non-clinical service codes to their contract.

Add Clinical Codes Form [PDF] This form is to be used by Vendor Agencies who would like to add clinical service codes to their contract.

Remove Contracted Codes Form [PDF] This form is to be used by Vendor Agencies to remove any contracted service codes.

FidelityEHR Resources

 

FidelityEHR Helpdesk Access requests, tech support issues.

FidelityEHR User Manual [PDF]

Report Request

Vendor Complaint Form

This form is used to forward complaints regarding vendor services from Care Coordination or Erie County Staff. Please note that CCNY must receive this completed form to process any complaints.

CCNY Vendor Complaint Form [PDF]

Work with Us

If you would like a private consultation on how CCNY can help your organization deliver value-based healthcare, please fill out the form and we'll be in touch soon to start a dialog.

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