North Carolina

Participant Employer Forms

Authorization to Obtain PHI Information Form Form 2678 Form 8821 Form SS-4 Form W-9 Innovations Acumen Authorization Form Innovations Employer Agreement MCO Referral Form NC MCO Employee Background Checks Approval Process & Form NC Budget Estimator Planning Tool 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 Innovations Employer Packet NC Innovations Overtime Request Form NC Innovations Pay Schedule July 2022 to June 2023 NC Show Me the Money NC Trillium Bi-Weekly Pay Schedule 7-2022 to 6-2023 NC Vendor EFT Form Overtime Estimator Tool Withdrawal to Obtain PHI Information Form NC Bonus and Reimbursement Request Guide

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

DCI Portal

Withdrawal to Obtain PHI Information Form NC Budget Estimator Planning Tool NC Alliance Employee Packet Form W-4 Authorization to Obtain PHI Information Form Alliance Paying for Supports Packet Alliance Max Bill Pay Rate Alliance Employer Packet Alliance Accrued Funds Payment Request Form NC Online Purchase Request Form NC Vendor Payment Form

DCI Portal

Withdrawal to Obtain PHI Information Form Partners Request for Employee Bonus and Reimbursement Partners Paying Supports Packet Partners Employer Packet Partners Background Check Payment Request Form NC Partners Max Bill Pay Rates NC Partners BHM Employee packet NC Budget Estimator Planning Tool Form W-4 Authorization to Obtain PHI Information Form NC Online Purchase Request Form NC Vendor Payment Form

DCI Portal

Withdrawal to Obtain PHI Information Form Sandhills Max Pay Rates Form Sandhills Employer Packet NC Sandhills Paying Supports Packet NC Sandhills Employee packet NC Sandhills Budget Surplus Payment Req Form NC Budget Estimator Planning Tool Form W-4 Authorization to Obtain PHI Information Form NC Vendor Payment Form NC Online Purchase Request Form

DCI Portal

Trillium Employer Packet Withdrawal to Obtain PHI Information Form Trillium Reserve Payment Request Form Trillium Max Pay Rates Trillium Health Resources Introduction Webinar NC Trillium Paying Supports packet 6 NC Trillium Employee packet NC Budget Estimator Planning Tool Form W-4 Authorization to Obtain PHI Information Form NC Vendor Payment Form NC Online Purchase Request Form

DCI Portal

Withdrawal to Obtain PHI Information Form Vaya Employer Packet NC Vaya Paying Supports Packet NC Vaya Max Bill Pay Rates NC Vaya Hep B Form NC Vaya Fund Balance Payment Req Form REV 12 NC Vaya Employee Packet NC Budget Estimator Planning Tool Form W-4 Authorization to Obtain PHI Information Form NC Vendor Payment Form NC Online Purchase Request Form

DCI Portal