Form Dcd-0094 - Approval Of Supplemental Rate
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2APPROVAL OF SUPPLEMENTAL RATE
To be Completed by the Local Department of Social Services
or Local Purchasing Agency
Date:_____________________Agency:__________________________________________________
Case Name/Number:________________________________________________________________
Child’s Name/DCS ID#:_____________________________________________________________
Child’s Date of Birth/Rate Group:_____________________________________________________
Provider’s Name:___________________________________________________________________
Child’s Special Needs:_______________________________________________________________
√
Chil
d’s Special Needs Verified by Referral Agency: Check (
) one agency.
□
Children’s Developmental Services Agency (CDSA)
□
Local Education Agency (LEA)
□
Local Management Entity (LME)
□
Child Service Coordination Program (CSCP)
□
□
DCD-0454A and DCD-0454B submitted by provider:
Yes
No
Amount of Supplemental Payment Request: $___________________________________________
Specify Purpose of Supplemental Payment:
_______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
To be Completed by the Division of Child Development’s (DCD) Subsidy Services Consultant
□
□
√
Request is:
Approved
Denied
Please check (
)
Comments:________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_____________________________________________________
__________________________
Signature of DCD Subsidy Services Consultant
Date
White Original and Yellow Copy:
DCD Subsidy Services Consultant
DCD-0094
Rev. 9/07
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