Self directed services / fiscal intermediary (FI)

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important forms

How to Submit for Payments
how_to_submit_for_payments.docx
File Size: 243 kb
File Type: docx
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Self-Directed Services- Actualized Costs- Lease
actualized_costs_lease.tif
File Size: 391 kb
File Type: tif
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​Applicant Consent Form for Fingerprinting for Justice Center Criminal Background Check Unit
fi_background_check_updated.pdf
File Size: 3571 kb
File Type: pdf
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DSP Performance Evaluation
written_tool_for_dsp_evaluation.pdf
File Size: 475 kb
File Type: pdf
Download File
interview_tool_for_dsp_evaluation__1_.pdf
File Size: 561 kb
File Type: pdf
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Family Reimbursement Payment Receipt
family_reimbursed_respite_-_fi.pdf
File Size: 370 kb
File Type: pdf
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Expense Report- Direct Payment
expense_worksheet_-_direct_payment_new_2017.xlsx
File Size: 14 kb
File Type: xlsx
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IDGS Community Class Submission
idgs_community_class_vetting.tiff
File Size: 256 kb
File Type: tiff
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Participant Mileage Form
mileage_worksheet_new_2017.xlsx
File Size: 11 kb
File Type: xlsx
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Expense Reimbursement Form
expense_worksheet_-_reimbursement_new_2017.xlsx
File Size: 14 kb
File Type: xlsx
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Employment in Self Directed Services/Compensation and Benefits
working_in_sds_salary___time_off_addendum_-_final.docx
File Size: 94 kb
File Type: docx
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FI contacts:

Diane Lagoumis 
FI Senior Manager
DianeL@eed-a.org
631-369-7345 ext. 109

Tracy Zimmerman
FI Coordinator
TracyZ@eed-a.org
631-369-7345 ext. 112

Katherine Haas
Self-Direction Coordinator
KatherineH@eed-a.org
​631-369-7345 ext. 244
​
Sally Easter
​FI Software Support
SallyE@eed-a.org
631-369-7345 ext. 142
Out of New York State Services
out_of_new_york_state_services.pdf
File Size: 118 kb
File Type: pdf
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Employee Salary Form
self-direction_employee_salary_form_new.pdf
File Size: 442 kb
File Type: pdf
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