Page 41

Appendix 41 DEPARTMENT OF HEALTH AND HUMAN SERVICES LINCOLN OFFICE 1050 "N" ST LINCOLN NE 68508

Office Number - Worker Name - Phone Number - Toll Free Number - Date of Notice - Mail Date - PROVIDER AUTHORIZATION Child Care Telephone: Provider ID: On behalf of the client named below, the Department of Health and Human Services authorizes you to provide the service indicated below. This document authorizes you to provide and bill for the listed service in accordance with the units of service, the rate of charge and the authorization period stated. In providing authorized services you accept responsibility and liability for injury to client(s) or damage to clients' property resulting from negligence by you or your employees in the provision of services. All billings must be received by the Department within ninety (90) days of service provision. Case Number: Telephone: Changes in the parent/caretaker's schedule of 10 or more hours in a week must be reported to the case manager. The case manager must be notified if a child does not attend the child care for three consecutive days. Authorized Service: Service Code: Authorized Clients Client ID# Authorization # JONES, FRANCIE Authorized Period: Authorized Units: Authorized Rate: Provider Authorization (Sample Form)

loading…

Page 41

Official source

Appendix 41 DEPARTMENT OF HEALTH AND HUMAN SERVICES LINCOLN OFFICE 1050 "N" ST LINCOLN NE 68508

Office Number - Worker Name - Phone Number - Toll Free Number - Date of Notice - Mail Date - PROVIDER AUTHORIZATION Child Care Telephone: Provider ID: On behalf of the client named below, the Department of Health and Human Services authorizes you to provide the service indicated below. This document authorizes you to provide and bill for the listed service in accordance with the units of service, the rate of charge and the authorization period stated. In providing authorized services you accept responsibility and liability for injury to client(s) or damage to clients' property resulting from negligence by you or your employees in the provision of services. All billings must be received by the Department within ninety (90) days of service provision. Case Number: Telephone: Changes in the parent/caretaker's schedule of 10 or more hours in a week must be reported to the case manager. The case manager must be notified if a child does not attend the child care for three consecutive days. Authorized Service: Service Code: Authorized Clients Client ID# Authorization # JONES, FRANCIE Authorized Period: Authorized Units: Authorized Rate: Provider Authorization (Sample Form)