North Carolina

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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 2678
Form 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

EVV Live-In Caregiver Attestation
Form I-9
Form 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

Cardinals Expenditures Request form
Cardinal Semi-Monthly Pay Schedule July 2021 to June 2022
Cardinal Request for Vendor Reimbursement Form
Cardinal Financial Support Services Agreement

C. Partners Forms

Partners Semi-Monthly Pay Schedule July 2021 to June 2022
Partners Request for Vendor Reimbursement Form
Partners Budgetary Overage Payment Request

D. Sandhills Forms

NC Sandhills Vendor Payment Request
NC Sandhills Semi-Monthly Pay Schedule July 2021 to June 2022
NC Sandhills Budget Surplus Payment Req Form

E. Trillium Forms

Trillium Vendor Payment Request Form
Trillium Reserve Payment Request Form

Trillium Health Resources Introduction Webinar

Trillium Health Resources Introduction Webinar
NC Innovations Bi-Weekly Pay Schedule July 2021 to June 2022

F. Vaya Forms

Vaya Semi-Monthly Pay Schedule July 2021 to June 2022
NC Vaya Vendor Payment Request updated
NC Vaya Fund Balance Payment Req Form REV