Fillable Form Dcd-0454b - Provider Information Form printable pdf download

County Case #:

Return Form To:

________________________

___________________________________________

PROVIDER INFORMATION FORM

To obtain the supplemental payment, the child has to be identified as a child with special needs by the regional

Child

Development Services Agency (CDSA) or local education agency (LEA). The child will need to be

determined eligible for subsidized child care by the local department of social services (DSS) or other local

purchasing agency (LPA). Eligibility for the supplemental payment is contingent upon the provider's compliance

with the activities designated for the provider in the child's Individualized Family Service Plan (IFSP) or

Individualized Education Program (IEP). Also, consultation and specialized therapies or educational services are

to be paid with other applicable funds, not subsidized child care funds. Payment will be made only for approved

child care services provided by an eligible provider for as long as public child care funds are available to the local

purchasing agency and the child remains eligible for assistance.

To be completed by the Provider:

1. Name of Facility or Individual Provider: ______________________________________________________________

2. Facility ID No.: _______________________________________Telephone: (

)

3. License or G.S. 110-106 number of facility if not currently approved to participate in the subsidized child care

program (or indicate if nonlicensed home provider):

4. Name of child with special needs: ______________________________________________Date of Birth: _________

5. I am requesting the Special Needs Supplemental Rate for the additional costs incurred for serving the above named

child.

________________________________

________________________________________

_____________

Provider’s Name (Please Print)

Signature of Provider

Date

Provider and staff of the regional Child Development Services Agency or local education agency: In order to

receive payment for the supplement, the provider must complete the Provider Section of Form DCD-0454B and

return all three copies to the local DSS or LPA. The local DSS or LPA completes the section below indicating the

supplement approval and keeps the white original. The local DSS or LPA returns the pink copy to the provider

and the yellow copy to CDSA or the LEA. A completed copy of the form, Child with Special Needs Additional

Expense Documentation (DCD-0454A), must be attached to this form for approval.

TO BE COMPLETED BY THE LOCAL DEPARTMENT OF SOCIAL SERVICES OR LOCAL PURCHASING AGENCY:

Amount Approved for Monthly Supplemental Payment: $

Approved By:

Name of County or LPA:

Signature of Agency Representative:

Effective Date of Supplemental Payment:

White Original: Local DSS or LPA

Pink Copy: Provider

Yellow Copy:

CDSA

or LEA

DCD-0454B

Rev. 01/05

Form Dcd-0454b - Provider Information Form

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