Page 198

198

PURPOSE OF FORM The completed form provides verification necessary to determine compliance with immunization requirements. USE OF FORM The form must be given to applicants/recipients to use to supply verification that a child has received required immunizations. The form must be completed by a physician or local health department personnel. COPIES One per child. File completed form in the case record.

INSTRUCTIONS FOR PREPARING THE FORM The worker must complete the case/agency information section at the top of the form and the child’s name, social security number, and date of birth in the section completed by the doctor/provider.

Appendix R. Child Care Purchase of Service Order Instructions

NUMBER 032-05-0540-02-eng (07/12)

(Please refer to the Finance Guidelines Manual for LDSS Section 5.20 – Purchase of Service for specific Purchase of Service guidance)

PURPOSE OF FORM This form is used to order services from the child care provider. If the provider accepts a Purchase f Service Order (POSO), it enters into a contract for a specific purchase. This form is also used for early termination of an existing POSO. A revised POSO will be available to the provider in EPPIC any time the information on the POSO needs revision, as revisions change the terms of the contract

USE OF FORM This form is prepared by the child care case worker (worker) by entering information into the VaCMS and the fiscal officer, or the director’s designee, as noted, and is available to the provider in EPPIC.

COPIES This form is generated from the VaCMS. The form is sent to the recipient. The correspondence ID# and mailing date must be recorded in the case narrative, if printed locally. The form will be available to the provider in EPPIC.

DISPOSITION The form is pre-filled according to the information entered by the child care worker into the VaCMS.