Form Jfs 01292 - Publicly Funded Child Care Request For Ohio Ecc Payment Adjustment printable pdf download

Form Jfs 01292 - Publicly Funded Child Care Request For Ohio Ecc Payment Adjustment

Ohio Department of Job and Family Services

PUBLICLY FUNDED CHILD CARE

REQUEST FOR OHIO ECC PAYMENT ADJUSTMENT

COUNTY REQUEST

PROVIDER REQUEST

County Department of Job and Family Services: send this form to

child_care_adjustment@jfs.ohio.gov

. Providers: send this

form to the County Department of Job and Family Services.

SECTION I. PROVIDER AND CASE INFORMATION

Provider Name

Provider ID Number

Authorization Number

Caretaker First Name

Caretaker Last Name

Case Number (10 digits)

Child First Name

Child Last Name

Child ID Number (12 digits)

Service Week/Period (MM/DD/YYYY - MM/DD/YYYY)

Settlement Date (MM/DD/YYYY)

SECTION II. REASON FOR REQUEST

(only submit request if payment is being changed. You must use one form for each week.)

Reason for the request (check one)

Swipe error (No new attendance)

Authorization change

Caretaker withdrew without notice

(attendance record required)

Manual Claim Error (County request only)

Describe the reason for this request

SECTION III. ATTENDANCE DURING SERVICE WEEK/PERIOD

Attendance (enter in and out time, including hours and minutes with AM or PM indicator)

Enter Sunday Begin Date:

(MM/DD/YYYY) for the service/week period of attendance you are submitting

Time in (HH:MM)

Time out (HH:MM)

Time in (HH:MM)

Time out (HH:MM)

Day of Week

check AM/PM

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

SECTION IV. SIGNATURES

(By signing below, I agree that my child was in care at this provider during the dates and times entered

above)

Caretaker Signature

Date Caretaker Signs (MM/DD/YYYY)

Caretaker Name (please print)

Phone Number of Caretaker

(By signing below, I agree that I provided care to this child at this provider during the dates and times entered above)

Date Provider/Designee Signs (MM/DD/YYYY)

Provider/Designee Signature

Provider/Designee Name (please print)

Phone Number of Provider/Designee

The total payment amount is subject to payment rules and procedures required by the Ohio Department of Job and Family

Services. The provider must submit this completed form to the County Department of Job and Family Services to request a

payment adjustment. This form must be received or post marked no later than 7 weeks from the last day of the week of

service being submitted unless otherwise determined by the ODJFS Bureau of State Hearings.

JFS 01292 (Rev. 9/2014)

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Form Jfs 01292 - Publicly Funded Child Care Request For Ohio Ecc Payment Adjustment

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