FMS PAY LLC - SDP Vendor Annual Re-Certification

This is your annual re-certification. As part of federal Medicaid Waiver requirements (Appendix C), we review every service provider file each year to confirm it is complete and current. Most vendors finish in 10-15 minutes. Please have handy: your current business license, any professional certifications, and — if you are a regional center vendor — your current rate letter. We will confirm whether anything further is needed.

Your billing category determines your invoicing and documentation requirements in SDP. Answer the questions below, taken from the DDS 'Billing Requirements in SDP' flowchart (Enclosure A) — every vendor falls into exactly one of three categories. For full details, see our SDP invoice requirements article.

Services must be physically rendered within California (SDP funds must be utilized in-state per W&I Code §4519). An out-of-state business can qualify if its services are delivered in person inside California — but virtual or remote services delivered from outside California count as rendered out of state, even if the client is in California. For example, virtual tutoring provided by a New Jersey company to a California client is considered out of state and is ineligible. Read our out-of-state vendors article.

The questions in this section come from SDP vendor qualification requirements ("Appendix C"). Learn more in our Vendor Qualifications knowledge base article.

FMS Pay uses this to report payments to the IRS and to certify your California withholding status. For a sole proprietor or disregarded entity, enter the owner's name on line 1 and the business name on line 2. Our IRS W-9 tips article (with instructional video) may help.

Part II — Certification. Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and (2) I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the IRS that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and (3) I am a U.S. citizen or other U.S. person; and (4) The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. If you have been notified by the IRS that you are currently subject to backup withholding, contact FMS Pay before signing. If you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return, you must strike out item 2 above — contact connect@fmspay.com before signing so we can document this. The official Form W-9 and its instructions are available at irs.gov/FormW9 or from FMS Pay upon request. The IRS does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.

Civil penalty for false information with respect to withholding: if you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Failure to furnish TIN: if you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless due to reasonable cause and not willful neglect.

CA Withholding: We keep exactly one of these forms on file for each vendor. It is your responsibility to determine which form applies to you and to complete it accurately — FMS Pay cannot provide tax advice. Most California-based vendors complete Form 590; nonresident vendors sometimes complete Form 587. If you're unsure, see our CA-590 and CA-587 tax forms article, FTB Publication 1017, or consult your tax advisor. Withholding agent for both: FMS PAY LLC. Please contact FMS Pay for additional support, as typically out of state vendors cannot be funded in SDP.

This intake process is for independent vendors and service providers only. Please read and acknowledge each statement below — each checkbox is required.

DDS Special Incident Reporting requirements: Vendor/Provider SIR Reporting Guidelines (PDF)

Does EVV apply to you? The 21st Century CURES Act (2016) requires states to set up an Electronic Visit Verification (EVV) system for Medicaid-funded personal care and home health care services — typically services involving hands-on personal care (dressing, grooming, bathing, hygiene), respite, or similar in-home or community supports. An EVV system electronically verifies: type of service performed; individual receiving the service; date of the service; location of service delivery; individual providing the services; and time the service begins and ends. Services in SDP are required to be eligible for federal financial participation per W&I Code §4685.8(e). If your services are subject to EVV per DDS Directive: report your visits into the Sandata state aggregator under FMS Pay's vendor number — PY2892. This applies to ALL vendors subject to EVV, including traditional Regional Center vendors serving SDP clients — do not use your traditional RC vendor number for SDP clients.

Resources: our EVV knowledge base article · dds.ca.gov/services/evv · EVV@dds.ca.gov · Sandata (state EVV contractor).

*PRIVACY NOTICE: I certify that all information and signatures in this packet are true, correct, and complete, and that typing my name above constitutes my electronic signature. Any information may also be provided to the State Controller's Office, the California Department of Justice, the Department of Consumer Affairs, other state or local agencies as appropriate, fiscal intermediaries, managed care plans, the Federal Bureau of Investigation, the Internal Revenue Service, Medicare Fiscal Intermediaries, Centers for Medicare and Medicaid Services, Office of the Inspector General, Medicaid, or licensing programs in other states.

*FALSE CLAIMS ACT NOTICE: I certify that all information and signatures in this packet are true, correct, and complete, and that typing my name above constitutes my electronic signature. Payment for SDP services is made from federal and/or state funds, and the falsification or concealment of a material fact may be prosecuted under federal and state laws. I understand that submitting false, fraudulent, or inflated claims — including billing for services not rendered, overbilling, duplicate billing, or misrepresenting the services provided — may constitute a violation of the federal False Claims Act and the California False Claims Act and may be prosecuted. If FMS Pay LLC, the Regional Center, the Department of Developmental Services, or any state or federal agency determines that funds were paid based on such claims, or were otherwise paid in error or not in accordance with program requirements, I agree to promptly repay those funds upon demand, and I authorize FMS Pay LLC to recover such amounts, including by offsetting or withholding them against pending or future payments to me. I understand suspected fraud may be referred to the Regional Center, DDS, and law enforcement, and may result in termination of my vendor file. I agree to retain records sufficient to disclose the full extent of services provided for a minimum of three years from the date of service and to provide them upon request.

Questions? connect@fmspay.com · Vendor intake guide · FMS Pay knowledge base · FMS Pay LLC · San Diego, CA

FMS Pay has partnered with SDP Spark, a secure online platform built for California's Self-Determination Program. Your invoices will be submitted through SDP Spark and flow to the client/representative for approval, and you'll be able to see your invoice processing and paid status for easier Accounts Receivable reconciliation. Once your vendor file is established, we will email you an SDP Spark access code — use it to register at sdpspark.com/signup. See our SDP Spark vendor enrollment article — and join our weekly support & office hours if you'd like hands-on help.