Child Care Claim - Oklahoma Department Of Human Services
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1
2*10AD121E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES
Child Care Claim
Part I. Provider information
Provider name
Contract number
Phone
Address
Street
Social Security/Employer's ID no.
City
State
Zip
Month/year of care provided
Return to:
Oklahoma Department of Human Services
Attention: Finance Division - EBD Claims
P.O. Box 53323
Oklahoma City, OK 73152-3323
Part II. Reason for submission of a manual child care claim
You must check one box below:
Care provided in child's own home
Military base provider
Point of service (POS) machine not issued within 10 days of care being authorized
Client did not swipe attendance. You must explain in detail the reason swipes
could not be made electronically:
I certify that this claim is submitted in accordance with contract specifications and
Oklahoma Department of Human Services (OKDHS) policy and under penalty of
perjury, is true and correct to the best of my knowledge and belief and understand that
any false statements on my part may result in prosecution for fraud. I further certify
that the back of this claim has been reviewed, signed, and dated by the client, parent,
guardian, or caretaker, or by me, as provider upon termination. I understand that
failure to complete this claim properly will result in a vendor overpayment.
Provider signature
Date
Part III. Audit/approval - Reserved for approving office only
Amount adjusted
$
Amount approved
$
Reviewer signature
Date
OKDHS revised 8-14-2006
10AD121E (ADM-12-S)
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