Free Missouri Cd 147 PDF Template Modify Form Online

Free Missouri Cd 147 PDF Template

The Missouri CD 147 form is a formal request used by child care providers to resolve payment discrepancies with the Missouri Department of Social Services. This essential document initiates a review process for payments when issues arise, ensuring that providers can address any inaccuracies related to their invoices. To begin the resolution process, providers must complete this form and submit it along with required attendance records within specified timeframes.

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Table of Contents

How to Use Missouri Cd 147

Completing the Missouri Cd 147 form is a crucial step for child care providers who need to address payment discrepancies. After filling out the form, it must be submitted within 60 days from the end of the service month in question. Be sure to include all necessary attendance records to support your request.

  1. Child Care Provider/Facility: Enter the name of your child care facility or your name as the provider.
  2. Contact Name: Fill in the name of the person who can be contacted regarding this request.
  3. DVN: Input your Departmental Vendor Number (DVN) associated with your facility or as a provider.
  4. Telephone Number: Provide a contact number for inquiries related to the resolution request.
  5. Mailing Address: Enter the complete mailing address for your facility or yourself as the provider.
  6. City: Specify the city for the mailing address provided above.
  7. State: Indicate the state for the mailing address.
  8. ZIP Code: Fill in the ZIP code for the mailing address.
  9. Child's Name: List the name of the child for whom you are requesting a payment review.
  10. Date of Birth: Enter the child's date of birth.
  11. DCN: Input the child's DCN (Department Client Number).
  12. Service Month/Year: Fill in the month and year for which you are requesting the review.
  13. Reason for Review: Choose the letter (A-E) that corresponds to the reason for your request.
  14. Explanation: Provide any additional information that supports your request for review. Attach extra pages if necessary.
  15. Return Address: Select the appropriate address from the dropdown menu for the Provider Relations Unit responsible for processing your payments.
  16. Provider Signature: Sign the form to validate your request.
  17. Date: Write the date on which you are submitting the request.

After completing the form, attach the necessary attendance records and send your request to the selected address. Keep a copy of the form and all attachments for your records, as they will not be returned. Submitting this request does not guarantee payment, but it is essential for initiating the review process.

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Document Features

Fact Name Description
Purpose The Missouri CD 147 form is used by child care providers to request a review of payment discrepancies for child care services rendered.
Submission Deadline Providers must submit the form within 60 days after the service month ends to initiate the review process.
Invoice Requirements This form is also necessary when submitting invoices that are 60 days late, requiring an explanation for the delay.
Attendance Records Complete attendance records for each child and service month must accompany the CD 147 form for it to be processed.
Review Notification Upon submission, providers will be notified of the review outcome, but submission does not guarantee payment.
Governing Law The form is governed by Missouri Revised Statutes, Chapter 210, which outlines the regulations for child care services.
Contact Information Providers must include their contact information, including the Departmental Vendor Number, to ensure proper processing of their requests.

Key takeaways

Filling out the Missouri CD 147 form is an important step for child care providers seeking to resolve payment discrepancies. Here are key takeaways to ensure a smooth process:

  • Timely Submission: Complete and submit the form within 60 days of the end of the service month in question.
  • Invoice Requirements: Use this form if submitting regular invoices that are 60 days past the service month or the "Return by" date on the invoice.
  • Explanation Section: Include a detailed explanation for any late submissions in the designated section of the form.
  • Attendance Records: Attach complete attendance records for each child and service month listed on the form.
  • Review Process: Understand that submitting the form does not guarantee payment; it initiates a review of your request.
  • Keep Copies: Retain a copy of the completed form and all attached records for your own records, as they will not be returned.