Form Fc 31 - Accreditation Reimbursement Request
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1STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
ACCREDITATION REIMBURSEMENT REQUEST
Per Welfare and Institutions Code Section 11462 and Section 11463
SECTION I – PROVIDER INFORMATION
Corporation/Licensee Name:
Rates Provider Number:
Zip Code:
Address:
City:
Contact Person:
Email Address:
Telephone Number:
Amount Requested:
Providers Signature:
SECTION II – ACCREDITATION INFORMATION
ACCREDITING BODY:
Accreditation Started: __________________
Date
Please mark the appropriate box.
Accreditation Completed: _______________
Date
The Council on Accreditation (COA)
Commission on Accreditation of Rehabilitation Facilities (CARF)
The Joint Commission (TJC)
SECTION III – FCARB AND ACCOUNTING USE ONLY
Federal PCA Code 22358: _______________
State PCA Code 12354: ________________
Amount to be applied
Amount to be applied
Object Code: 706
Total to be paid: ______________________
Index Code: 9990
Invoice #: _____________ _____________ _____________ ___________ _____________
Approved: ______ Denied: ______ (Ineligible because fees were not paid 7/1/16 or after)
Rates Consultant Signature: ____________________________________________________
Please attach the invoice from the accrediting agency showing the billing amount
and cancelled check, credit card, receipt or online receipt to this form and mail
with form STD 204 (Payee Data Record) to:
Foster Care Audits and Rates Branch
744 P. Street, M.S. 8-11-74
Sacramento, CA 95814
FC 31 (11/16)
Accreditation Reimbursement Request
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