BILL FOR CHILD CARE SERVICES by bxk16778

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									DFS 201                                                                                                                                       STATE OF WYOMING
(01/03)                                                                                                                           DEPARTMENT OF FAMILY SERVICES
                                                              BILL FOR CHILD CARE SERVICES
                                                  THIS FORM MUST BE COMPLETED IN BLUE OR BLACK INK
CHILD CARE FOR THE MONTH OF:                                                              AUTHORIZATION NUMBER:

AUTHORIZED NUMBER OF:                          PART DAYS:                                   FULL DAYS:                                  HOURS:

Provider Information:                                                                     Case Information:
Name:                                                                                     Case Number:
Provider SSN                                               Provider
or EIN:                                                    Number:                        Parent’s Name:
Provider Address:                                                                         Child’s Full Name:
Provider Telephone:                                                                       Age of Child:

Phone where care is provided (if different):                                              Worker’s Name:

Complete all unshaded areas of the billing form below to indicate the actual hours the child was in your care. The billing form should only reflect the type of payments (i.e.
hours, full days, part days) allowed on the child care authorization. SEE BACK OF THE GOLDENROD SHEET FOR SPECIFIC INSTRUCTIONS ON HOW TO FILL OUT THIS
                                                                                  .
FORM. ONLY TIME THE PARENT WAS WORKING OR ATTENDING SCHOOL SHOULD BE BILLED TO DFS Do not bill DFS for any periods of care when you know the parent
was not participating in an approved activity. The parent should be billed directly for child care not approved by DFS.


DATE     TIME      TIME      TIME      TIME    HOURS      PART       FULL     AGENCY      DATE      TIME      TIME        TIME   TIME     HOURS    PART     FULL      AGENCY
           IN      OUT         IN      OUT                DAY        DAY       USE                    IN      OUT           IN   OUT               DAY      DAY         USE

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PAYMENT CALCULATION (See back of Goldenrod Sheet for specific instructions):
Rates Per Authorization: HOURLY:                               PART DAY:                                                           FULL DAY:

                                    DFS:                   Parent:                DFS:                      Parent:                DFS:                   Parent:

                                 A.                      B.                        C.                         D.                  DFS USE ONLY            DFS USE ONLY
                          Authorized Time         DFS Payment Amt.           Providers Usual           Parent’s Portion            DFS Payable            Amount of Time
                             Attended             Per Authorization               Rate                  (Parent's rate x             Amount                 Authorized
                                                                                                       hours/days in "A")

Hours

Part Days

Full Days
PARENT/CARETAKER’S OBLIGATION TO PROVIDER: Complete the appropriate option below:
IF DFS payment amount ("B") is GREATER than Provider's Usual Rate ("C"):
E. Enter the amount from "C" above         F. Enter the Parent's Contribution from "D"                                      G.   Subtract "F" from "E" THIS IS THE
                                                Above                                                                            AMOUNT DFS WILL PAY



                                                                                       OR
IF DFS payment amount ("B") is LESS than Provider's Usual Rate ("C"):
H. Enter the amount from "C" above           I. Enter the DFS payment amount from "B"                                       J. Subtract "I" from "H" THIS IS THE
                                                 Above                                                                         AMOUNT PARENT OWES PROVIDER



                  **DFS HAS NO RESPONSIBILITY FOR PAYMENT OF THE CLIENT’S PORTION OF THE MONTHLY TOTAL.**
Did anyone else contribute toward child care costs? Yes No If yes, please note in COMMENTS below who contributed and how much.
COMMENTS:
CERTIFICATION: I certify under PENALTY OF PERJURY , this claim and the items included therein for payment are correct and just in all respects and
that this form was not signed prior to last date of service.


Signature of Provider                                                   Date Signed              Signature of Parent                                            Date Signed
DFS USE ONLY:

       County:
       Audited By:                                                                Date:
       Payment By:                                                                Date:
       Comments:

White: DFS-CO; Canary – Field Office (Fiscal); Pink – Provider; Goldenrod – Client
DFS 201                                                                                                  STATE OF WYOMING
(01/03)                                                                                      DEPARTMENT OF FAMILY SERVICES


                                          BILL FOR CHILD CARE SERVICES

FORM INSTRUCTIONS:

PURPOSE:        To report child care costs monthly to DFS.

PROCEDURE: Complete this form IN BLUE OR BLACK INK each month a child is in care. This form is completed by
the child care provider. Complete a separate billing form when there is more than one Authorization for the child in one
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month. Return this form to the local DFS office no later than the 5 working day of the month. Bills received by DFS 90
days or more after the month of the service WILL NOT be honored.

SPECIFIC INSTRUCTIONS:
•  Fill in all of the information at the top of the form.
•  The provider’s number, case number, and information about the number of authorized hours and DFS payment
   amounts can be found on the Authorization Form (DFS-200). Do not bill DFS for child care services before you
   have received the Authorization Form.
•  Using each child’s attendance record, fill in the time the child is left at the center/home under the “time-in” section and
   enter the time the child is picked up under the “time-out” section. There is an additional “time-in” and “time-out”
   column to be used if the child enters and leaves the center/home again during the day. For example, all of the
   columns would be filled out if the child left the center/home to attend school and returned to the child care facility later
   in the day.
•  Child Care assistance is only authorized for the times the parent/caretaker is either working or attending
   school. Only bill DFS for this time. Any child care that is used by the parent outside of work or school hours
   should be billed directly to the parent and not included on the bill to DFS.
•  Enter the total time the child was in child care at the center/home each day. Round the total time for each day to
   the nearest one-quarter hour under the “Hours” column. Any time within 8 minutes is considered a quarter hour.
   Child Care providers may attach their own time record log to verify the time the child was in care if both the provider
   and parent/caretaker have signed and dated the log sheet.
•  Licensed providers who are paid on a part or full day basis should check the appropriate column. The following
   calculation should be used to determine which charge is appropriate:
         Full day = 5 or more hours per day.
         Part day = Less than 5 hours per day.

Complete the PAYMENT CALCULATION as follows:
•  Using the Authorization Form (DFS 200), enter the rates shown on the authorization for the appropriate type(s) of
   payment for both DFS and the parent.
•  Enter the following information in the unshaded areas of the billing calculation table:
   A. Authorized Time Attended: Enter the number of hours, part days and/or full days the child was in your care
       while the parent was working or attending school.
   B. DFS Rate x Time Attended: Multiply the DFS rate for the type of care times the number of authorized hours, part
       days and/or full days the child was in care. Enter the total in this area.
   C. Provider’s Usual Rate: Enter the amount you charge for this amount of care. If your facility has full time, monthly
       or weekly rates and this is the amount of payment you would expect from all of your paying customers, enter this
       amount in the full day rate section. If your rates are set on an hourly, part or full day basis, multiply your rates by
       the hours part days and/or full days attended and enter this amount in the appropriate section.
   D. Parent's Portion: Multiply the Parent's Rate from the authorization times the Authorized Time Attended in section
       "A".

          The remainder of the Payment Calculation will be completed by DFS for use in issuing payment.

Complete the PARENT/CARETAKER’S OBLIGATION TO PROVIDER as follows:
    When the DFS Payment Amount ("B") is GREATER than the Provider's Usual Rate ("C"), complete "E"
    through "G" as follows:
    E. Enter the Provider's Usual Rate from "C".
    F. Enter the Parent's Portion from "D" above.
    G. Subtract the amount in "F" from "E". This is the amount DFS will base payment on. Due to rounding of
        fractions, the actual amount paid may be slightly more or less than the amount in "G".

    When the DFS Payment Amount ("B") is LESS than the Provider's Usual Rate ("C"), complete "H" through "J"
    as follows:
    H. Enter the Provider's Usual Rate from "C".
    I. Enter the DFS Payment Amount from "B" above.
    J. Subtract the amount in "I" from "H". This is the amount Parent will owe the Provider.


DO NOT CHARGE DFS MORE THAN YOU CHARGE YOUR PRIVATE PAY CUSTOMERS. DFS RESERVES THE
RIGHT TO MAKE FINAL DETERMINATION OF THE PAYABLE AMOUNT BASED ON THE RESULTS OF THE AUDIT.

When all portions of the billing form are complete, both the provider and parent/caretaker should sign and date
the form. DO NOT SIGN THE FORM UNTIL ALL SERVICES HAVE BEEN PROVIDED AND THE FORM IS
COMPLETE.
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Submit the white and canary copies of the billing form to the local DFS office by the 5 working day of the month.
BILLS RECEIVED BY DFS 90 DAYS OR MORE AFTER THE MONTH OF THE SERVICE WILL NOT BE HONORED.

								
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