Information for Service Providers

Office of Mental Health

Acting Commissioner Kristin M. Woodlock, RN, MPA

Governor Andrew M. Cuomo

Language Access | 中文 | PyCCКИЙ | Español | Kreyòl Ayisyen

New York State Office of Mental Health
Document Requirements for OMH Contracts
With Amendment Number “0”
(e.g. Contract C00XXXX/0 from the Contract Summary Report by Contract)

Item	Non-Residential Funds	Residential Funds	Shelter Plus Care Funds	Legislative Special Projects
Contract face page and signature page (107kb)	X	X	X	X
State of New York Agreement (51kb)	X	X	X	X
Appendix A (Standard Clauses) (170kb)	X	X	X	X
Appendix A-1 (OMH Specific Clauses) (186kb)	X	X	X	X
Appendix B (Budget) (34kb)	X¹	X¹	X¹	X
Appendix C (Schedule of Payments) (94kb)	X	X		X
Appendix C-1 (Payment and Reporting Schedule for Shelter Plus Care Programs Only) (45kb)			X
Appendix D (Program Work Plan) (33kb)	X	X	X	X
Appendix E (To be completed by OMH) (42kb)	X⁴	X⁴
Appendix F (Business Associate Agreement) (115kb)	X	X	X	X
Appendix H (Shelter Plus Care Regulations) (161kb)			X
Appendix X (Modification/Renewal Agreement) (62kb)	X²	X²	X²	X
Non-Licensed Program Rider/Certification of Compliance (Exhibit A) (71kb)	X	X³	X
Vendor Responsibility Questionnaire	X	X	X	X
Proof of NYS Workers' Compensation (or exemption) (67kb)	X	X	X	X
Proof of NYS Disability Benefits Insurance (or exemption) (67kb)	X	X	X	X
NY Charities Registration (or exemption) (34kb)	X	X	X	X
Federal Certification Form ¹ 102kb)	X⁵		X⁵
Federal Certification Form ² (71kb)	X⁵		X⁵
Residential Program Rider (71kb)		X
Assisted Outpatient Treatment Rider (26kb)	X⁶	X⁶
Community Projects Rider (28kb)				X
Certification Appendix (Disclosure & Accountability Certification) (Less than or equal to $50,000) (106kb)				X
Certification Appendix (Disclosure & Accountability Certification) (Greater than $50,000) (88kb)				X

¹ Budget is submitted electronically through Consolidated Fiscal Reporting System (CFRS); do not submit paper copy.
² Do not complete; leave blank and include with package.
³ Not required if contract includes only licensed programs.
⁴ Required if contract includes licensed programs.
⁵ Original signed Federal certification forms are required if Federal funds are included in the contract.
⁶ For outpatient treatment programs involving court ordered population only.

February 2013

Comments or questions about the information on this page can be directed to the Community Budget & Financial Management (CBFM) Group.

Last Modified: 2/20/2013

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