North Carolina
EVV Innovations Waiver deadline is 6/30/2021
98.8% Customer Satisfaction Average for 2020
To contact Acumen Fiscal Agent, please call (866) 811-3099 or fax (855) 262-3292.
A. Innovations Waiver Forms
Participant Employer Forms
Form 2678Form 8821
Form SS-4
Form W-9
Innovations Acumen Authorization Form
Innovations Employer Agreement
MCO Referral Form
NC Client Termination Form
NC Client and Employer Change Information Form
NC Dept of Commerce POA
NC Dept of Revenue POA
NC Employee Termination Form
NC Vendor EFT Form
Direct Care Employee Forms
Form I-9Form NC-4
Form W-4
NC Background Check Forms
NC Innovations Employee Agreement
NC Innovations Employee Change Information Form
NC Innovations Employee Rate Form
NC Innovations Pay Selection and Direct Deposit Form
NC-4EZ Withholding Form
B. Cardinal Forms
Cardinal Request for Vendor Reimbursement FormCardinal July 2020 to June 2021 Payment Schedule
Cardinal Financial Support Services Agreement
Cardinal Expenditures Request Form
C. Partners Forms
Partners Request for Vendor Reimbursement FormPartners July 2020 to June 2021 Payment Schedule
Partners Budgetary Overage Payment Request
D. Sandhills Forms
NC Sandhills Vendor Payment Request FormNC Sandhills December 2020 to June 2021 Payment Schedule
NC Sandhills Budget Surplus Request Form
E. Trillium Forms
Trillium Vendor Payment Request FormTrillium Reserve Payment Request Form
Trillium Health Resources July 2020 to June 2021 Payment Schedule
Trillium Health Resources Introduction Webinar
Trillium Health Resources Introduction WebinarF. Vaya Forms
Vaya Vendor Payment Request FormVaya Request for Fund Balance Payment Form
Vaya July 2020 to June 2021 Payment Schedule