Information for Service Providers

Office of Mental Health

Acting Commissioner Kristin M. Woodlock, RN, MPA

Governor Andrew M. Cuomo

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New York State Office of Mental Health
Document Requirements for OMH Contracts
With Amendment Numbers Greater Than “0”
(e.g. Contract C00XXXX/1 from the Contract Summary Report by Contract)

Item	Non-Residential Funds	Residential Funds	Shelter Plus Care Funds
Contract cover page and signature page
State of New York Agreement
Appendix A (Standard Clauses) (139kb)	X	X	X
Appendix A-1 (Office of Mental Health Specific Clauses) (170kb)	X	X	X
Appendix B (Budget) ( 34kb)	X¹	X¹	X¹
Appendix C (Schedule of Payments) (94kb)	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
Appendix E (To be completed by OMH) (42kb)	X³	X³
Appendix F (Business Associate Agreement)
Appendix H (Shelter Plus Care Regulations) (161kb)			X
Appendix X (Modification/Renewal Agreement) (62kb)	X	X	X
Non-Licensed Program Rider/Certification of Compliance (Exhibit A) (71kb)	X	X²	X
Vendor Responsibility Questionnaire	X	X	X
Proof of NYS Workers' Compensation (or exemption) (67kb)	X	X	X
Proof of NYS Disability Benefits Insurance (or exemption) (67kb)	X	X	X
NY Charities Registration (or exemption) (34kb)	X	X	X
Federal Certification Form 1 (102kb)	X⁴		X⁴
Federal Certification Form 2 ( 71kb)	X⁴		X⁴
Residential Program Rider (71kb)		X⁵
Assisted Outpatient Treatment Rider (26kb)	X⁶	X⁶
Community Projects Rider (for Legislative Special Grants only) (28kb)

¹ Budget is submitted electronically through Consolidated Fiscal Reporting System (CFRS); do not submit paper copy.
² Not required if contract includes only licensed programs.
³ Required if contract includes licensed programs.
⁴ Original signed Federal certification forms are required if Federal funds are included in the contract.
⁵ If applicable, e.g., change in the number of beds.
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: 4/30/2013

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