DECCD Provider Report of Underpayment/Overpayment Form

Please use this form to report any problems with an over-payment or under-payment. Payment adjustment request MUST be submitted within 10 days of the disputed payment in order to be processed. NOTE: Sign In/Out Sheets must be submitted in addition to this form.

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*

State*

County

Select or enter value

Zipcode*

Requested Change*

Adjustment Request*

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/Month of Care/Days Missing From Payment*

Example: John Doe, June, 1 through 15

Documents can be sent to the following:

Fax Number: 601-359-4422 Email Address: cc.payment@mdhs.ms.gov Provider Document Upload: https://app.smartsheet.com/b/form/dc884facd6fb4db9b2baea768d6b8c1e Mailing Address: DECCD P. O. Box 352 Jackson, MS 39205

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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