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 1 17 2 18 3 19 4 20 5 21 6 22 7 23 8 24 9 25 10 26 11 27 12 28 13 29 14 30 15 31 16 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 th 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. th 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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