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CC-214 (1-14) - REVERSE CO-PAYMENT/RATE INFORMATION A Provider/Parent/Guardian’s Agreement for Child Care Charges (CC-208) shall be completed for all DES children in care. A new agreement shall be completed prior to each change in child care rates, co-payment amounts or additional charges. 1. DES eligible parents may be required to pay a portion of their child care costs. 2. DES co-payment amounts are indicated on the Certificate of Authorization. The part day co-payment amount is one half the full day co-payment. 3. The client pays the required co-payment directly to the child care provider. 4. The provider is required to maintain co-payment balances separately from any other monies the client owes. All money paid by the DES eligible parents will be applied to the co-payment balance. 5. If the client has not paid the co-payment for two (2) or more weeks, and satisfactory arrangements have not been made, the provider will complete the Unpaid Co-Payment Worksheet (CCA-1021A) and forward it to the client’s Child Care Specialist. 6. If co-payments in arrears are not paid or satisfactory arrangement to pay have not been made with the provider, DES may terminate client benefits. 7. DES will not process outstanding co-payment balances more than 180 days old. 8. In some cases, clients may have fees in addition to the DES established co-payment (additional child care charges). Note: DES will not become involved in disputes regarding outstanding additional fees owed by clients. 9. The provider shall not bill DES for more than the maximum units authorized. The client is responsible for payment of any additional services used. The actual units utilized by the client are not to exceed the maximum number of units authorized. 10. The provider shall give the client an itemized, dated receipt for co-payments and other fees paid, if requested. Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, (602) 542-6825; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. • Disponible en español en línea o en la oficina local. Page 41 CC-214 (1-14) – Arizona Department of Economic Security