DECCD Provider Change of Child/Ledger Info Form

Use this form to report problems with any information on the ledger including issues with rates, duplicate children, missing children and children who no longer attend and should be removed from the ledger.

This form is solely for Provider Information only. Please DO NOT upload Change of Provider forms, Parent Application, New Child or Redetermination Documents to this form. Any document uploaded to this form that is not used for Provider Information will be at risk for serious delay in the processing of those documents. To access the web form for Parent Application documents, please click the Parent Document Upload link https://app.smartsheet.com/b/form/92ca98a8c3364fa298d7c05e2356cff5

Client Type*

"In-Home" Provider (Non-licensed)

Licensed Provider

Provider/Center Name*

Provider ID Number*

Phone Number*

Email Address*

City*

County*

Select or enter value

State*

Zipcode*

Requested Change*

Incorrect Reimbursement Rates*

Yes

Child Name/Current Rate/Corrected Rate

Example: John Doe, 0.00, 0.00

Incorrect Care Status (FT vs FT/PT)*

If YES, Sign In/Sign Out Sheets must be submitted to DECCD. You may send documents through FAX, EMAIL, POSTAL MAIL or UPLOAD to this form.

Yes

Child Name/Current Status/Corrected Status

Example: John Doe, FT, FT/PT

File Attachments

If you would like to upload a copy of any document(s) that are required for the specific change you are trying to make, please upload the document(s) here.

Drag and drop files here or

Provider Confirmation*

By checking this box, I certify that this information submitted is true and correct to the best of my knowledge. I also certify that I am currently employed at this center and am authorized to submit this information.

Send me a copy of my responses

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