Rate Certification Form Outpatient - Delaware Department Of Services For Children, Youth And Their Families Page 2

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State of Delaware
Division of Management Support Services
The Department of Services
Cost Recovery Unit
For Children, Youth and
Their Families
RATE CERTIFICATION FORM - Outpatient
Usual and Customary Charges to the General Public
Complete a separate form for each location for which services are contracted by DSCYF. If a service is program funded and not
per diem, please check “Yes” for “Program Funded.” Please list both your “Usual and Customary Rate” and your “State of Delaware
Contracted Rate.”
Contract ID # (found on your DSCYF Contract)
Contract Period
From:
To:
Program Funded
YES
NO
DSCYF
Usual and
Your DMA
Procedure
Procedure
Service Description
Contract
Customary
Medicaid
Billing Code
Modifier
Rate
Total Rate
Rate
e.g.: Individual
Psychotherapy, Masters
90837
HO
$87.57
$250.00
$86.00
Level, 60 minutes
Is your agency enrolled with Medicaid?
YES
NO
If yes, in which States?
Signature of Authorized Representative
Title of Authorized Representative
Printed Name of Authorized Representative
Agency Name
Date
Phone
Email
Please provide a copy of your State’s Medicaid letter showing your enrollment and your rate(s).
Outpatient
Revised 12/2013
Page 2 of 4

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