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.

 Contract Forms

Schedule 3.1: Vendor Demographic Data Form[PDF]   Use this form to assess individual skills, knowledge and professional experience for each working. It will allow you identify service codes these individuals will be working under in Fidelity EHR and Family First systems. This form was last updated 7.28.13

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 the Erie County’s system of care within the wrap around process. It will give you a description of the service, qualifications necessary to provide this service, and reimbursement fees categorized by vendor code.

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.

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

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

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 3.18.12

9000 Code Reimbursement Form[PDF]

9000 Code Reimbursement Form Guidance [PDF]

9000 Code Process Map[PDF]

9000 Code Reimbursement Guidance Document [PDF]

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]

Fidelity EHR Access Forms 

These forms are used to gain access to Fidelity EHR for any Erie County Children’s System of Care Staff who are NOT Vendor or Care Coordinators.

CARES Access Form [PDF]

County Access Form [PDF]

Non-Provider Access Form [PDF]