Fillable - CDID Vendor Payment Form 20180312 C

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- CDID Vendor Payment Form 20180312 C

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V
ENDORPAYMENTREQUESTFORM
Rev.03/12/2018
02216
Mail/DropOff:280E.CorporateDr,Ste150
Meridan,ID83642
Email:infoCDID@ConsumerDirectCare.com
Fax:877‐898‐0417
HaveQuestions?Phone:877‐898‐0470
RequestsforVendorPayments
areduebymidnightonMonday
oftimesheetweekforpaymentto
normallybeissuedonthe
followingpaydate.
ForInternalUseOnly
ParticipantName&ID W‐9*
VendorName&Address Agreement*
Serv.CodeMatchesAuth Amountapproved
Item/ServiceAuthorized Fundsavailable
*ifneeded
ConsumerDirectCareNetwork(CDCN)musthaveauthorizationfromthepayer(State,MCO,orCounty)toprocess
paymentforallgoodsandservices.
ThegoodsorservicesmustbelistedontheParticipant’sapprovedbudget.
Allreceiptsand/orinvoicesmustbeincludedwiththisVendorPaymentRequestFormtoensureproperprocessing.
TheEmployerisresponsibleforallowingadequateprocessingtimeforpaymentstobemadebyduedates.
Incorrectorincompletesubmissionsmaybereturnedforcorrection,whichwillresultindelayofpayment.
Makecheckpayableto NEWAddress–Mustcheckhere
Name IndicateNEWaddressbelow
Address
City/State/Zip
Vendoris:AgencyIndependentContractor
OtherBusiness,Professional,orServiceProvider
Avendorprovidingservice(s)must submita
newW‐9if changingaddress.
Dateof
Invoice
(mm/dd/yy)
Service
Code
DescriptionofService
Quantity
(Units)
Rateper
Unit
Total
Dollar
Amount








TotalCheckAmount
*Pleaseattachacopyofthevoidedreceipt,agencyinvoice,orsignedbid/estimate.*
IapproveCDCNtoissuepaymentdirectlytotheabove‐namedVendorfortheservices/goodslistedabove.Icertifythat
theaboveVendorprovidedservicesinaccordancewiththeplan.FalsificationofthisVendorPaymentRequestis
consideredMedicaidFraudandmayresultindismissalfromtheprogramand/orcriminalprosecution.
________________________________________________________________________/____/_______
Employer/GuardianSignature PrintName Date(mm/dd/yyyy)
NameofIndividualReceivingServices CDCNParticipant/EmployerID#
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- CDID Vendor Payment Form 20180312 C

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Completed 10 September 2021

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