Legally Certified Provider (LCP) Legally Certified In-Home Provider (LCP) Application Packet

Transcription

1 HCS/CC160 New12/10 StateofMontana DepartmentofPublicHealthandHumanServices HumanandCommunityServicesDivision ChildCareServicesBureau Legally Certified Provider (LCP) Legally Certified In-Home Provider (LCP) Application Packet Thisapplicationpacketincludesthefollowingitems: BasicInformation WhatisaLegallyCertifiedProvider(LCP)orLegallyCertifiedInHomeProvider(LCI)? Dane slaw MedicationAdministrationInformation ApplicationForms ThebelowapplicationformsareneededinordertoapplytobeaLegallyCertifiedProvider.The checklistthatisontheapplicationwillgointofurtherdetailregardingeachform. LegallyCertifiedProviderApplication(includestheapplicationchecklist) FamilyAssociationForm/HealthandSafetyChecklist W9TaxIDForm Releaseofinformation ReleaseofInformationforFingerprints StatementofHealth ProviderRightsandResponsibilities MedicationAdministrationAttestation(Tobecompletedwithparentandturnedinwithapplication) ParentForms Thebelowformsareformsthataretobecompletedwiththeparent(s)ofthechild(ren)thatyouare goingtobeapprovedtocareforandkeptatthelocationwherecareisbeingdone. MedicationAuthorizationForm OvertheCounterMedicationAuthorizationForm ImmunizationWaiver ProviderProgramForms Thebelowformsareformsthataretobeusedforchildrenincare. Attendance(SignIn/SignOut)Log MedicationAdministrationLog MedicationError/IncidentReport PLEASESUBMITALL LEGALLYCERTIFIEDPROVIDER APPLICATIONMATERIALSTO:

2 Family sseekingchildcareassistancemustcompletethebestbeginningschildcare Scholarshipapplication.Theseapplicationsmustbeobtainedfromandsubmittedtotheir localchildcareresourceandreferralagency.pleaseseeagencylistingbelow. HRDCDistrict7 PhoneNumbers Counties 7North31stStreet BigHorn,Carbon,Stillwater Billings,MT SweetGrass,Treasure,Yellowstone ChildCareConnections PhoneNumbers Counties 1600EllisSt,Unit1A Gallatin,Meagher,Park Bozeman,MT Butte4C s PhoneNumbers Counties 101EastBroadway Beaverhead,DeerLodge,Granite Butte,MT Madison,Powell,SilverBow HiLineHomePrograms,INC PhoneNumbers Counties 6053rdAveSo Daniels,Roosevelt,Phillips,Sheridan, Glasgow,MT Valley ChildCareSolutions PhoneNumbers Counties 2022ndAveSoSuite Cascade,Chouteau,Glacier,Pondera, GreatFalls,MT Teton,Toole DistIVHRDCChildCareLink PhoneNumbers Counties 22295thAve Blaine,Hill,Liberty Havre,MT ChildCarePartnerships PhoneNumbers Counties 901N.BentonAve Broadwater,Jefferson,Lewis&Clark Helena,MT TheNurturingCenter PhoneNumbers Counties 1463rdAveW Flathead,Lake,Lincoln,Sanders Kalispell,MT HRDCDistVIChildCareLink PhoneNumbers Counties 3001stAveN,Suite Fergus,GoldenValley,JudithBasin, Lewistown,MT Musselshell,Petroleum,Wheatland ChildCareEducation&Support PhoneNumbers Counties 2200BoxElder,Suite Carter,Custer,Dawson,Fallon,Garfield, MilesCity,MT McCone,PowderRiver,Prairie,Richland, Rosebud,Wibaux ChildCareResources PhoneNumbers Counties 105E.Pine,LowerLevel Mineral,Missoula,Ravalli Missoula,MT

3 WHAT IS A LEGALLY CERTIFIED PROVIDER (LCP( LCP) OR LEGALLY CERTIFIED IN-HOME PROVIDER (LCI( LCI) OF CHILD CARE? Federal regulations guarantee the right of parental choice in selecting child care. As a result, parents may choose a friend or family member to provide child care and receive state payment. These individuals are known as Legally Certified Providers. There are two situations in which a Legally Certified Provider can participate in the State of Montana Best Beginnings Child Care Scholarship (child care assistance program). In the Provider s home (LCP) The provider cares for the children in the provider s home for two or fewer children from different families or all the children of one family. The provider receives the child care assistance payment from the State after the invoice is submitted to the Child Care Resource & Referral agency. In the Child s home (LCI) The provider cares for the children of one family, in the Child s home. The parent receives the child care assistance payment from the State after the invoice is submitted to the Child Care Resource & Referral agency. The parent must pay their provider in accordance with applicable labor laws. WHO CAN BE A LEGALLY CERTIFIED PROVIDER OR LEGALLY CERTIFIED IN-HOME PROVIDER? 1. A person who is at least 18 years old. 2. A person who is mentally and physically capable of providing child care that meets safety, health and other basic child care requirements and standards. 3. A friend or relative who does not live with the child. 4. A grandparent, great-grandparent, aunt or uncle who lives with the child and is not part of the TANF or Child Care household. Relation is verified through birth certificate records. The CCR&R can access birth certificates for those persons born in Montana. It is the responsibility of the applicant to provide birth certificates if born in any other state or country. PLEASE NOTE: All Legally Certified Providers and Legally Certified In-Home Providers must attend a basic child care orientation within sixty days of approval. The orientation covers basic health and safety precautions; as well as, pertinent child development information and ideas for appropriate activities and discipline.

4 DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES BRIAN SCHWEITZER GOVERNOR STATE OF MONTANA JOAN MILES DIRECTOR 2401 Colonial Drive 2 nd floor PO BOX HELENA, MT Effective October 1, 2005, Montana child-care providers will be subject to a new law under the jurisdiction of the Montana Department of Justice. Dane s Law makes it a felony for any employee, owner, household member, volunteer or operator of a day care facility to administer medication either prescription or non-prescription--to a child without the written consent of the child s parent. The law also prohibits the inappropriate administration of medications. The law does provide an exception for certain medical emergencies when parental consent cannot be obtained. In such cases, a provider would have to obtain the written authorization from the child s physician, or be verbally directed to administer the medication from a medical practitioner, an emergency services provider, or a 911 responder. The penalty for giving a child medication without parental consent can be up to 20 years in jail and up to a $50,000 fine. In anticipation of Dane s Law and the implementation of future day care rules pertaining to medication administration, The Child Care Licensing Program has developed sample documents for providers to use. Use of these documents is voluntary at this time. The documents include: Medication Authorization Form A Medication Administration Log (with instructions for use); and Medication Error/Incident Report These forms are located at and are not copyright protected; they can be downloaded and used as is, or providers may modify the documents in accordance to their program. However, if a facility chooses to modify these forms, it is critical that the same basic information contained on the above documents is used. If you are interested in obtaining a full copy of Dane s Law, you may do so by logging onto Should you have questions or concerns about Dane s Law, or the medication administration documents, please contact your local child-care licensor, or the Child Care Licensing Program Manager, Becky Fleming-Siebenaler, at

5 StateofMontana DepartmentofPublicHealthandHumanServices HumanandCommunityServicesDivision ChildCareServicesBureau LEGALLY CERTIFIED PROVIDER (LCP) or LEGALLY CERTIFIED IN-HOME PROVIDER APPLICATION What is a Legally Certified Provider or a LegallyCertified In-home Provider? ALegallyCertifiedProvider(LCP)orLegallyCertifiedInhomeprovider(LCI)isaprovidercertificationcategory thatisusedforstatepaymentpurposesonly.lcpandlciprovidersaregenerallymatchedtofamiliesonaone toonebasis.inallcasesrelatedtolcis,theparentisconsideredtheemployerofthelci,notthestate.for additionalinformationpleaseseetheenclosed2pageflierentitled WhatisaLegallyCertifiedProvider(LCP)or LegallyCertifiedInhomeprovider(LCI)ofchildcare. What criteria must I meet to be approved as an LCP or LCI? ApplicantsforstatusasaLegallyCertifiedProviders[LCP]orLegallyCertifiedInhomeProvider[LCI]mustmeet allofthefollowingconditions: Theprovidermustbeage18orolder. Theprovidermustbementallyandphysicallycapableofprovidingchildcarethatmeetssafety, health,andotherbasicchildcarerequirementsandstandards,whichmayrequireastatementof healthcompletedbyaphysician,psychologist,orpsychiatrist TheprovidermustnothaveasubstantiatedreportwithChild/AdultProtectiveServicesinvolving harm,physicalabuse,orsexualabusetochildrenoradults Theprovidermustnothaveacriminalconvictioninvolvingharm,physicalabuse,orsexualabuse tochildrenoradults. The provider must not be included in the parent s Temporary Assistance for Needy Families [TANF]cashassistancepayment. The provider must list an eligible family for whom the provider will provide care in their application. Theprovidermustnotprovidecarewhilehomeschooling. Theprovidermustprovidecareinahomesetting;eithertheirhomeorthehomeoftheparent. Do I have to take orientation training? LegallyCertifiedProvidersarerequiredtotakeorientationtrainingwithin60daysofcertificationapproval. However,orientationcanbetakenpriortocertificationapproval.Please,contactyourlocalChildCareResource andreferralagencyforupcomingorientationdates. How do I apply? Toapplypleasecompletetheappropriateapplicationmaterialsaslistedonthefollowingpageandsubmitthem tothecentralizedservicesprovider. How long will it take? TheLCP/LCIapplicationprocessmaytakeinexcessof30daysfromthedateallapplicationmaterialsare received,especiallyifoutofstatebackgroundchecksareneeded.tohelpavoidpossibledelaysorlapsesin service,submitalltherequireddocumentationwithyourapplication.

6 What is the payment process? Afterafamilyisdeterminedeligibletoreceiveassistanceandtheproviderisapprovedtoprovidecare,Invoices ar ed,totheprovider,duringthemonthinwhichcareisprovided.invoicesshallbesubmittedtothelocal ChildCareResourceandReferral(CCR&R)agencyimmediatelyfollowingthemonthinwhichcareisprovided. InvoicesareprocessedonthefifthbusinessdayofthemonthandonsubsequentTuesdays.Paymentsgenerally arrivein2to3businessdaysafterprocessing.paymentsforlci sonlyaresenttotheparent,whoistopaythe LCIProvider.Pleasesee ChildCareProviderRightsandResponsibilities formoreinformation. Currentpaymentratescanbefoundathttp:// What will my effective date for payment be? BoththeparentandtheLegallyCertifiedProviders[LCP]orLegallyCertifiedInhomeProvider[LCI]must bedeterminedeligibletoparticipateinthebestbeginningsscholarshipprogram.theeffectivedatefora LegallyCertifiedProviderwillbethedateyourcompletedapplicationisreceivedattheCentralizedServices ProviderofficeorthedatetheparentisdeterminedeligibleforaBestBeginningsChildCareScholarship, whicheverislater. Application and Supporting Documentation Checklist and Instructions Checktobesureyouhavesubmittedthefollowingdocuments. LEGALLYCERTIFIEDPROVIDER/LEGALLYCERTIFIEDINHOMEPROVIDERAPPLICATION mustbecompletedinfull,signed,dated,andnotarized W9TAXIDFORM(SeeinstructionsonthebackoftheW9form) AmissingorincompleteW9willcauseadelayinpayments AnewW9needstobecompletedifyouraddresschanges. LCP:ThetopportionoftheW9needstobecompleted,includingyourname,addressandmark individual/soleproprietor.includeyourss$andsignature LCI:Whencareisgivenintheparent shome,theparentmustfilloutthew9,asthepayment goestotheparent,anditistheresponsibilityoftheparenttopaythelui. LCP/LCIRELEASEOFINFORMATIONFORM(mustbecompletedinfull,signed,dated,andnotarized) LCP:Tobecompletedbytheprovidereachpersonover18livinginthehome LCI:Tobecompletedbytheprovider RELEASEOFINFORMATIONFORFINGERPRINTS(mustbecompletedinfull,signed,dated,andnotarized) TobecompletedwhenanindividualhaslivedoutsidetheStateofMontana BackgroundchecksforthosewhohavelivedoutsideoftheUnitedStatesaretheapplicant s responsibilityanddocumentationconcerningcitizenship,agreencardorvisa,mustalsobe supplied WesternIdentificationNetwork(WIN)Check$10fee,forthosewhohavelivedinanyofthe followingstates:alaska,idaho,montana,nevada,oregon,utah,washington,andwyoming FBIFingerprintCheck$29.25fee;forthosewhohavelivedoutsideanyoftheWINstates LCP:Tobecompletedbytheprovidereachpersonover18livinginthehome LCI:Tobecompletedbytheprovider STATEMENTOFHEALTH(mustbecompletedinfull,signedanddated) LCP:Tobecompletedbytheprovidereachpersonover18livinginthehome LCI:Tobecompletedbytheprovider PROVIDERRIGHTSANDRESPONSIBILITIES FAMILYASSOCIATIONFORM/HEALTHANDSAFETYCHECKLIST ThisformindicatesthefamilythattheLCP/LCIwillbeprovidingcarefor. Boththeparentandprovidermustsignthisformindicatingthatbasichealthandsafety considerationshavebeenaddressed. MEDICATIONADMINISTRATIONATTESTATION BoththeparentandprovidermustcompletetheMedicationAdministrationAttestation

7 CCR&RLCPSTAFFONLY PROVIDERID PROVIDERNAME MONTANA LEGALLY CERTIFIED PROVIDER or LEGALLY CERTIFIED IN-HOME PROVIDER APPLICATION 1. I AM APPLYING TO BE A LegallyCertifiedProvider(Carewillbeprovidedinmyhome) LegallyCertifiedInHomeProvider(Carewillbeprovidedinthechild shome) HaveyoueverbeenaCertifiedorRegisteredChildCareProviderinMontanaorinanyotherstate? Yes No Ifyes,whattypeofproviderhaveyoubeen? LegallyCertifiedProvider FamilyChildCareProvider GroupChildCareProvider Other Ifyes,when? Where?(MTCity) (MTCounty) CERTIFICATION BEGINDATE ENDDATE CCR&RDATESTAMP LCPWORKERNAME 2. APPLICANT ThisisthepersonwhoisrequestingtobetheLegallyCertifiedProviderandassumesresponsibilityfor followingtheprogramrulesandrequirements,includingpenaltiesandrepaymentofanyoverpaidbenefits. PROVIDERNAME LASTNAME FIRSTNAME MIDDLENAME ADDRESS(physical) CITY STATE ZIP COUNTY TRIBALRESERVATION MAILINGADDRESS(ifdifferent) CITY STATE ZIP COUNTY TRIBALRESERVATION HOMEPHONE WORKPHONE OTHERPHONE WorkersInitials Date

8 3. FAMILY MEMBERS ForLegallyCertifiedProviders,wherecareisprovidedintheprovidershome Theproviderandeveryadult(18yearsandolder)inthehomemustbelistedbelow ForLegallyCertifiedInHomeProviders,wherecareisprovidedinthechild shome Theprovidermustbelistedbelow ALLindividualslistedbelowmustcompletethefollowingforms ReleaseofInformation Legally Certified Provider/Legally Certified InHome Provider Release of Information Criminal/ProtectiveServiceBackgroundChecksformmustbesignedbytheapplicantand anyadultoutsidethechild simmediatefamily.thisformisusedtoobtaininformation from the Montana Department of Justice and Montana Child Protective Services and AdultProtectiveServicesand,ifapplicableTribalLawenforcementsandChildProtective Services. ReleaseofInformationforFingerprints This form is only needed if the individual listed has lived outside the State of Montana StatementofHealth Applicantsmustmeetcertainpersonalhealthrequirements.Astheagencyresponsible forchildcarecertification,thedepartmentofpublichealthandhumanservices(dphhs) mustensurethatthehealthofallprovidersandfamilymembersisadequatetomeetthe demandsofthecarebeingprovided. FAMILYMEMBERS(First,MiddleLast) DATEOFBIRTH RELATIONSHIPTOAPPLICANT(you) 4. ORIENTATION AnorientationforLegallyCertifiedProvidersisrequiredwithin60daysofcertificationapproval. PleasecontactyourlocalChildCareResourceandReferralAgencyforupcomingorientationdates. HaveyoutakenLegallyCertifiedProviderOrientation(LCP) Yes,ItookLCPOrientationon No,However,IamscheduledtotakeLCPOrientationon No,IhavenottakenLCPOrientation,andIhavenotscheduledatimetotakeit. WorkersInitials Date

9 5. CHILD ABUSE AND NEGLECT Haveyoueverhadachildremovedfromyourhome? Yes No HaveyouoranyonelivinginyourhomebeeninvestigatedforpossibleabuseorneglectbytheDepartment,a childwelfareagencyinanotherstate,orlawenforcement? Yes No If Yes, Whatisthechild sname? Whatisyourrelationshipwiththechild? Whereandwhendidthishappen?(pleasegivedates) 6. CRIMINAL CHARGES / CONVICTIONS Applicantsandprovidersmustmeetcertainrequirementssuchasbeingfreeofcriminalchargesand convictions.astheagencyresponsibleforchildcarecertification,thedepartmentofpublichealthand HumanServices(DPHHS)mustensurethesafetyofchildreninachildcaresetting.Incomplyingwiththis eachproviderandadultpersonsresidinginthehomemustcompletea ReleaseofInformationForm, to benotarizedandsubmittedwiththisapplication,alongwiththeapplicantcompletingthefollowing questions.thesequestionsapplytoallpersonsresidinginthehome. Haveyouoranypersonresidinginthehomelivedinanotherstate? Yes No If Yes, Pleaselistthestatesyouhavelivedin,inthelastfiveyears,andthedates: Haveyouoranypersonlivinginyourhomebeenconvictedof,pleadguiltyto,or Yes No currentlychargedwithacrimeclassifiedasanoffenseagainstanypersonorfamily? If Yes, givedetails,includingnameofperson,date,placeandnatureoftheconvictionanddisposition: Haveyouoranypersonlivinginthehomeeverbeennamedasaperpetratorina Yes No substantiatedreportofchildoradultabuseorneglect(orexploitationofanadult)? If Yes, Pleaseexplain. HaveyouoranypersonlivinginthehomebeenconvictedofacrimeInvolving,childor Yes No elderabuseorneglect,includingsexualabuse,physicalassault,orotheractofviolence? If Yes, Pleaseexplain. WorkersInitials Date

10 7. HEALTH Applicantsandprovidersmustmeetcertainpersonalhealthrequirements.Astheagencyresponsibleforchild carecertification,thedepartmentofpublichealthandhumanservices(dphhs)mustensurethatthehealth ofallprovidersandfamilymembersisadequatetomeetthedemandsofthecarebeingprovided.in complyingwiththiseachproviderandadultpersonsresidinginthehomemustcompletea Statementof HealthForm, tobesubmittedwiththisapplication. 8. ADDITIONAL COMMENTS 9. CERTIFICATIONS LegallyCertifiedProvidersONLY IcertifythatIresideandwillbeprovidingcareinmyhomeandIagreethatIamanindependent contractor IcertifythatIwillonlyprovidecaretothechildrenofonefamilyorthatIwillonlyprovidecaretotwo childrenfromseparatefamilies IcertifythatIwillbeprovidingcarelessthan24hourswithintheday IcertifythatIwillreviewanddiscusswiththeparentstheimmunizationrecordofthechildreninmy care;or,reviewanddiscussthewaiverindicatingparentalchoicenottoimmunize. IcertifythatIwillexaminethehomeforfireandsafetyconditions,forthepresenceofworkingsmoke detector,forplacementofafamilyfireescapeplananddiscusstheconditionswiththeparents; IcertifythatIwillinformparent(s)thatstatewillNOTmakepaymentsuntilthisproviderapplicationis approved. IcertifythatIwillreviewthehealthandsafetychecklistforLCPprovider swiththeparent. IconfirmthatneitherInoranyone,presentinthehome,havebeen,investigatedforanyallegedharm, orphysicalorsexualabusetochildrenoradults.ifthisstatementisfalse,iamprovidingthe informationrequiredbelowaboutwheretheinvestigationoccurred: CityCounty State Date WorkersInitials Date

11 9. CERTIFICATIONS (continued) LegallyCertifiedInHomeProvidersONLY IcertifythatIwillbeprovidingcareinthechild shome IcertifythatIwillonlyprovidecaretothechildrenofonefamily IcertifythatIwillbeprovidingcarelessthan24hourswithintheday IconfirmthatneitherInoranyone,presentinthehome,havebeen,investigatedforanyallegedharm, orphysicalorsexualabusetochildrenoradults.ifthisstatementisfalse,iamprovidingthe informationrequiredbelowaboutwheretheinvestigationoccurred: CityCounty State Date Iattestandaffirmthattheabovestatementsaretrueandcorrecttothebestofmyknowledgeandbelief.I authorizeadphhschildandadultprotectiveservicesbackgroundcheckandacriminalrecordsbackground check.ialsoagreetoattendmandatoryorientationtrainingwithin60calendardaysofthedatethatiam approvedtoprovidechildcareservices. ProviderSignature Date TOBECOMPLETEDBYANOTARYPUBLIC: Taken,sworn,andsubscribedbeforeme,this dayof A.D. PRINTNotaryPublicfortheStateofMontana SignatureNotaryPublicfortheStateofMontana Residingat MyCommissionExpires (month/day/4digityear) WorkersInitials Date

12 MONTANA LEGALLY CERTIFIED PROVIDER or LEGALLY CERTIFIED IN-HOME PROVIDER APPLICATION CCR&RLCPSTAFFONLY PROVIDERID PROVIDERNAME CERTIFICATION BEGINDATE ENDDATE CCR&RDATESTAMP FAMILY ASSOCIATION FORM ThisformistobeusedtoassociatethefamilythattheLCP/LCIwillbeprovidingcareto. 1. PROVIDER INFORMATION ThisistheLegallyCertifiedProviderwhowillbeprovidingcareforthefamilythatisreceivingchildcare assistanceandwhoislistedbelowin#2. PROVIDERNAME LCPWORKERNAME PV# LASTNAME FIRSTNAME MIDDLENAME ADDRESS(physical) CITY STATE ZIP COUNTY TRIBALRESERVATION HOMEPHONE WORKPHONE OTHERPHONE TANF:AreyouincludedintheParent stanffinancialgrant? Yes No 2. FAMILY INFORMATION Thisisthefamilywhocareisbeingprovidedtoandwhoisreceivingchildcareassistance HEADOFHOUSEHOLDNAME(Last,First,Middle) CASE#/CASEEVENT# ADDRESS(physical) CITY STATE ZIP COUNTY TRIBALRESERVATION NAMEOFCHILDRENINCARE(First,MiddleLast) DATEOFBIRTH RELATIONSHIPTOLCP/LCI WorkersInitials Date

13 HEALTH AND SAFETY CHECKLIST HealthandSafetyissuesshouldbeconsideredwhenarrangingforchildcare.Herearesometopicsaparent andchildcareprovidermaywanttodiscuss.formoreinformationregardingqualitychildcare,contactyour localchildcareresourceandreferralagency. No corporal punishment may be inflicted. YES NO PLEASE ANSWER ALL QUESTIONS by Initialing either YES OR NO Doparentshaveaccesstotheirchildrenatalltimes? Istheprovideringoodhealth? Istheprovidertrainedaboutbasichealthandsafetyissues? Istheproviderknowledgeableaboutchilddevelopmentissues? Doestheproviderwashhandsthoroughly,beforeandafterdiapering? Doestheproviderwashhandsthoroughly,beforepreparingfood? Hastheproviderreceivedguidelinesonhowto childproof thehome? Doestheprovidertalkeasilywiththechildrenandrespondtotheirneeds? Doestheemotionalclimatefosterhappinessandtrust? Doestheproviderofferlearningopportunitiestothechildren? Arechildren simmunizationscurrent? Areemergencytelephonenumbersandparenttelephonenumbersposted? IstheprovidertrainedinFirstAidandCPR? Doestheproviderhaveanemergencymedicalauthorizationformsignedbytheparent? Isafirstaidkitavailable? Aremealsandsnacksnutritious? Isthereaquietcomfortableplacefornaps? Istheplayequipmentsafe? Isthehomeclean? Arethechildrenexposedtosmoking? Arehazardsinaccessibletochildren,insideandout? Areelectricaloutletscovered? Areheatersventilatedandscreened? Arepoisonoussubstancesoutofreachofchildren? Aresmokedetectorsinplaceandoperational? Isafireextinguisheravailable? Arefirearmslockedandinaccessible? Areappropriateautomobilerestraints,suchascarseats,used? Bysigningbelow,IstatethatIhaveread,discussedandunderstandtheaboveinformation. Parent Date Provider Date Statepaymentisdependentupontheboththeparent seligibilityforchildcareassistanceandthe caregiversapprovalasanlcp/lciprovider.paymentsarenotassociatedwithstartofcare. WorkersInitials Date 2011,MontanaDepartmentofPublicHealthandHumanServices

14 State of Montana Department of Administration SW9 (4/2009) Substitute W-9 Print or Type Please see attachment or reverse for complete instructions. Taxpayer Identification Number (TIN) Verification Legal Name (as entered with IRS) If Sole Proprietorship, enter your Last, First, MI Trade Name If doing business as (DBA) or enter business name of Sole Proprietorship Primary Address (for 1099 form) PO Box or Number and Street, City, State, ZIP + 4 Remit Address (where payment should be mailed, if different from Primary Address) PO Box or Number and Street, City, State, ZIP + 4 Department of Public Health and Human Services PO Box N Sanders Helena, MT Phone: Send faxes to: DO NOT send to IRS Entity Designation (check only one type) Corporation S-Corp C-Corp Do you provide medical or legal services? Yes No Individual Sole Proprietorship Partnership General Limited LLC (for federal tax purposes taxed as) Individual Partnership Corporation Estate/Trust Organization Exempt from Tax (under Section 501 (a)(b)(c)(d)(e)) Government Entity Other Taxpayer Identification Number (TIN) (Provide Only One) (If sole proprietorship provide FEIN, if applicable) Social Security Number Federal Employer Identification No Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number, AND 2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding. 3. I am a U.S. person (including a US resident alien). Printed Name Printed Title Telephone Number Signature Date Optional Direct Deposit Information (used at agency discretion) (all fields required to receive electronic payments) (Must Include a Voided Check, No Direct Deposit Slips Accepted) Your Bank Account Number Checking Name on Bank Account Bank Routing No. (ABA) THIS IS A: Savings New Direct Deposit Change of Existing Additional Direct Deposit Change Only Address (Please make this LEGIBLE) If you provide bank information and an address, we will send a message notifying you when an electronic payment is issued. We will NOT share your address with anyone or use it for any other purpose than communicating information about your electronic payments to you. If you have questions about completing this form, please call the Warrant Writer Unit at

15 SW9 (4/2009) Instructions for Completing Taxpayer Identification Number Verification (Substitute W-9) Legal Name As entered with IRS Individuals: Enter Last Name, First Name, MI Sole Proprietorships: Enter Last Name, First Name, MI LLC Single Owner: Enter owner's Last Name, First Name, MI All Others: Enter Legal Name of Business Trade Name Individuals: Leave Blank Sole Proprietorships: Enter Business Name LLC Single Owner: Enter LLC Business Name All Others: Complete only if doing business as a D/B/A Primary Address Address where 1099 should be mailed. Remit Address Address where payment should be mailed. Complete only if different from primary address. Entity Designation Check ONE box which describes the type of business entity. Taxpayer Identification Number LIST ONLY ONE: Social Security Number OR Employer Identification Number. See What Name and Number to Give the Requester at right. If you do not have a TIN, apply for one immediately. Individuals use federal form SS-05 which can be obtained from the Social Security Administration. Businesses and all other entities use federal form SS-04 which can be obtained from the Internal Revenue Service. Certification You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to furnish your correct TIN to persons who must file information returns with the IRS to report interest, dividends, and certain other income paid to you, mortgage interest you paid, the acquisition or abandonment of secured property, or contributions you made to an IRA. The IRS uses the numbers for identification purposes and to help verify the accuracy of your tax return. You must provide your TIN whether or not you are required to file a tax return. Payers must generally withhold 28% of taxable interest, dividend, and certain other payments to a payee who does not furnish a TIN to a payer. Certain penalties may also apply. What Name and Number to Give the Requester For this type of account: 1. Individual 2. Two or more individuals (joint account) 3. Custodian account of a minor (Uniform Gift to Minors Act) 4. a. The usual revocable savings trust (grantor is also trustee) b. So-called trust account that is not a legal or valid trust under state law 5. Sole proprietorship or Single- Owner LLC For this type of account: 6. Sole Proprietorship or Single- Owner LLC 7. A valid trust, estate, or pension trust 8. Corporate or LLC electing corporate status on Form Association, club, religious, charitable, educational, or other tax-exempt organization 10. Partnership or multi-member LLC 11. A broker or registered nominee 12. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district or prison) that receives agricultural program payments Give name and SSN of: The individual The actual owner of the account or, if combined funds, the first individual no the account 1 The minor 2 The grantor-trustee 1 The actual owner 1 The owner 3 Give name and EIN of: The owner 3 Legal entity 4 The corporation The organization The partnership The broker or nominee The public entity 1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person s number must be furnished. 2 Circle the minor s name and furnish the minor s SSN. 3 You must show your individual name, but you may also enter your business or DBA name. You may use either your SSN or EIN (if you have one). 4 List first and circle the name of the legal trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) NOTE: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

16 DPHHS-HCS/CC-077 (Revision 11-10) DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES STATE OF MONTANA - RELEASE OF INFORMATION - Legally Certified Providers (LCP) and Legally Certified In-Home Providers (LCI) Criminal and Protective Service Background Checks OFFICE USE CAPS# PS# PERSONAL INFORMATION Section A Current Name and Residence EthnicAffinity:HispanicorLatino Yes No Phone# LegalName: (First) (Middle) (Maiden) (Last) Aliases/OtherNamesUsed: ResidentialAddress: (Street) (City) (State)(Zip) MailingAddress: (Street) (City) (State)(Zip) Sex:[]Male[]FemaleDateofBirth: SocialSecurity# MaritalStatus: TribalAffiliation: Race: Section B Past Residences Haveyouever 1. livedinanotherstate? Yes No 2. livedonordoyounowliveinanareadesignatedasanindianreservation? Yes No Ifyouansweredyestotheanyoftheabovequestions: Pleasedeclarewhereyouhavelivedinthetablebelow. Outofstatebackgroundchecksortribalbackgroundchecks,willberequired.Thereisacostassociatedwiththesechecks. City County Reservation State DatesofResidency(From To) Section C Prior Caregiver Approvals Haveyoubeen certified/registered/licensedtocareforchildrenbefore? Yes No approved,inanycapacity,toprovidecareinachildcarefacility? Yes No IFYES:PleasegivetheDirector/FacilityNameandtheDatesatthefacility. (Director/FacilityName) (Dates) PLEASE COMPLETE BOTH SIDES OF THIS FORM WorkersInitials Date

17 LCP/LCI PROVIDER HOUSEHOLD INFORMATION Section D LCP/LCI Provider Household Member Status ThelegallyCertifiedProvider/InHomeProviderthatIliveatis: Provider#: LegallyCertifiedProvidersName: MailingAddress: Iam: thelegallycertifiedproviderapplicant legallycertifiedinhomeproviderapplicant or Iam: the spouseofthelcp/lciapplicant amemberoftheapplicant shousehold Section E Authorization Statement and Signature Aspartoftheinitialandsubsequentannualapplicationprocess,I, (applicantname)do herebyauthorizeanylawenforcementand/orprotectiveservicesagencytoreleaseanyrecordstheyhaveregardingme tothestateofmontana,departmentofpublichealthandhumanservices. I,amawarethat (provideroritsauthorizedrepresentative),hasrequested confidentialinformationfromthemontanadepartmentofpublichealthandhumanservices,inaccordancewith (3)(o),MCAaspartofareviewofmypersonalbackgroundinconnectionwithsaidentity. IamawarethatChildandFamilyServicesDivisionand,DepartmentofJusticerecordsmaycontaininformationthat couldadverselyaffectmylegallycertifiedproviderapproval.theserecordswillrelatetocriminalhistoryrecords,as wellasanyreport(s)ofchildabuseorneglectinmontanathatindicatesarisktochildren.recordsthatindicateariskto childrenarethosethatshowasubstantiationofchildabuse/neglectontheperson;and/orahistorythatshowsthata childinthecareofthepersonwasadjudicatedbyacourtasayouthinneedofcare,and/orahistorythatshowsthat thepersonhashadtheircaregiverrightstoachildterminated.asahouseholdmember,iunderstandthatiamalso subjecttotheaboverequirements. IamalsoawarethatalthoughtheentitiesorindividualsrequestingandreceivingconfidentialCFSDinformationare boundbylaworagreementwithdphhstoprotectorpreserveitsconfidentialnature,dphhshasnoabilityorauthority toensurethatconfidentialityismaintainedafterthisinformationisreleasedbydphhs. Infullacknowledgementoftheaboveinformationandnotice,IauthorizeCFSDtoprovidetherequestedconfidential informationtotheprovideroritsauthorizedrepresentativeidentifiedabove,andiherebyalsoreleasecfsdfromany claimsorcausesofactionwhichmaysubsequentlyarisefromreleaseofthisconfidentialinformation. NOTE:Anydeletionsoroversightsmayresultinthedenialofyourapplication. Signed: Date: (Tobesignedinfrontofanotary) TOBECOMPLETEDBYANOTARYPUBLIC: Taken,sworn,andsubscribedbeforemethis dayof A.D. PRINTNotaryPublicfortheStateofMontana SignatureNotaryPublicfortheStateofMontana Residingat MyCommissionExpires (month/day/4 digit year) WorkersInitials Date

18 Release of Information for Fingerprints Pursuant to the National Child Protection Act of 1993 as amended by the Volunteers for Children Act The National Child Protection Act of 1993 (NCPA), Public Law (Pub. L.) , as amended by the Volunteers for Children Act (VCA), Pub. L (Sections 221 and 222 of Crime Identification Technology Act of 1998), codified at 42 United States Code (U.S.C.) Sections 5119a and 5119c, authorizes a state and national criminal history background check to determine the fitness of an employee, or volunteer, or a person with unsupervised access to children, the elderly, or individuals with disabilities. Pursuant to the VCA, the entity (a) to which you have applied for employment or to serve as a volunteer, (b) by which you are employed or serve as a volunteer, or (c) which request a background check. You are entitled to obtain a copy of any background check report and challenge the accuracy and completeness of any information contained in any such report. The government agency shall access and review State and Federal criminal history records and shall make reasonable efforts to make a determination whether you have been convicted of, or are under pending indictment for, a crime that bears upon your fitness and shall convey that determination to the qualified entity. (First Name) (Middle Name) (Maiden Name) (Last Name) (Date of Birth) Address: (Street) (Apt) (City) (State) (Zip) I have been provided with a copy of this form. I have read and understood the foregoing and my information is true and correct to the best of my knowledge and belief. (Signature of Applicant) (Date) (Notary) (Date) (Residing At) (Commission Expires) 12/10

19 DPHHS-HCS/CC-127 (Rev 11/10) Page 1 of 2 STATE OF MONTANA DEPARTMENT OF PUBLIC HEALTH ANS HUMAN SERVICES EARLY CHILDHOOD SERVICES BUREAU LEGALLY CERTIFIED PROVIDER (LCP) LEGALLY CERTIFIED IN-HOME PROVIDER (LCI) PROGRAMS STATEMENT OF HEALTH FORM LEGALLYCERTIFIEDPROVIDERNAME:(PleasePrint) PV# NAME:(PleasePrint) PhoneNumber AddressCity,State,Zip SocialSecurityNumberBirthDate Iam:anapplicantapplyingtobe alegallycertifiedprovider legallycertifiedinhomeprovider or Iam: the spouseoftheapplicant amemberoftheapplicant shousehold Applicantsandhouseholdmembersmustmeetcertainhealthrequirements.AstheagencyresponsibleforapprovingLCP/LCI paymentnumbers,thedepartmentofpublichealthandhumanservices(dphhs)mustensurethatthehealthofeachprovideris adequatetomeetthedemandsofthecarebeingprovided. Pleaseanswerthefollowingquestionsbyenteringan X intheappropriateboxforeachquestion. TheCCR&RWorkeroverseeingtheLCP/LCImaterialspacketandtheLCP/LCISupervisorwhoapprovesthepaymentnumberwill reviewthisform.insomecases,theanswer yes toaquestionmayrequireanevaluationorastatementfromyourphysicianor otherappropriateprofessionaltosupportyourresponses.theanswer yes doesnotmeanyouwillautomaticallybedeniedasan LCP/LCI.Yourexplanationor,ifnecessary,yourphysician sorotherappropriateprofessional sstatementwillbetakeninto consideration.thepurposeofthequestionsistohelpdecideifyouhavehealthproblemsthatmayaffectyourabilitytosafelyprovide care.healthinformation,whichtheccr&rworker,assessesasneedingfollowupwillbeforwardedtothelcp/lcisupervisor.ifan evaluationorstatementisneeded,thesupervisorwillsendtherequiredinformationtothelcp/lciapplicant.anyevaluations,testsor visitstoyourphysicianorotherprofessional(s)mustbepaidbythelcp/lciapplicant. Yes NoDuringthepast3years,haveyouhadanydisablingchronicconditions,orphysical,mental,oremotionalillness requiringcarefromaphysician,psychologist,orotherprofessional? If Yes, pleasedescribe.includeadescriptionofanyvisionorhearingproblemandanylimitationonmobility.include treatmentandcurrentstatus.(youmayuseadditionalpaperifneeded.) Yes NoDoyousufferfromanyphysicalormentalhealthlimitations,whichmightaffectyourabilitytoprovidechildcare? If Yes, pleaseexplain.(youmayuseadditionalpaperifneeded.) Page2of2 Workers Initials Date

20 Yes NoAreyoucurrentlydiagnosed,receivingtherapyormedicationforamentalhealthproblem,whichmightaffectyour Abilitytoprovidecare? If Yes, pleaseexplain.(thereisadditionalroomonthenextpage.) Yes NoHaveyoureceivedcounselingortreatmentrelatedtochemicaldependency,drugsoralcoholwithinthepastthree years? If Yes, pleaseexplain.(youmayuseadditionalpaperifneeded.) Yes NoHaveyoueverbeenaddictedtodrugsand/oralcoholorhaveyoubeentreatedfordrugand/oralcoholabuse,within thepastthreeyears? If Yes, pleaseexplain.(youmayuseadditionalpaperifneeded.) AdditionalComments: PLEASEREAD,THENSIGNANDDATE: IcertifythatIhavereviewedtheforegoinginformationsuppliedbymeandthatitistrue,accurateandcompletetothebestofmy knowledge.ifurthercertifythatifullyunderstandthatanymisstatementonmypartincompletingthishealthstatementisgrounds fordenyingmyapplicationorforrevokingmypaymentnumbershouldonehavebeenissuedtomeonthebasisofthestatementsi havemadeherein.iunderstandthisinformationisconfidentialandistobeusedonlybythedepartmentofpublichealthand HumanServicesfortheadministrationoftheLegallyCertifiedProviderofChildCareprogram.Iherebyconsenttotheuseofthis informationforsuchpurposes. SIGNATURE: DATE: PleaseReturnTo: 2010,MontanaDepartmentofPublicHealthandHumanServices Workers Initials Date

21 PHHS-HCS/CC-018 (Rev. 12/10) STATEOFMONTANA DepartmentofPublicHealthandHumanServices HumanandCommunityServicesDivision CHILD CARE PROVIDER RIGHTS & RESPONSIBILITIES Best Beginnings Child Care Scholarship Program STATEUSONLY ReturntoCentralized ServicesProviderby: DateStamp Thegeneralchildcaresubsidyprogramrequirementsarecontainedonthisform, andmustbesharedwitheachstateassistedfamily.pleasereturnthecompleted Provider Name: Provider #: PV Telephone: Please read & initial each item: Initials Provider s Rights 1.IhavetherighttoreceiveacopyoftheChildCareCertificationPlan.Thisidentifiesthefamily s startdate,enddate,hoursofchildcareauthorized,andcopaymentamount,inwhichthe familyisresponsibleforpayingdirectlytome. 2.Ifthefamily scircumstanceschange,andtheyloseeligibilityforscholarshipassistancebefore theenddateshownonthechildcarecertificationplan,anoticewillb edtometen(10) daysbeforetheendofscholarshipassistance.ifthereisnochangetothecertificationplan duringthespanofeligibility,thecertificationplanbecomesthenoticetotheproviderwhen childcareeligibilitywillend. 3.Ihavetherighttotimelypaymentforchildcarescholarshipservices. 4.Icananticipatethefollowinginvoiceandpaymentschedule.Weekendsandholidaysdelaythis schedule: Invoicesar edtotheproviderduringthemonthinwhichcareisprovided. InvoicesshallbesubmittedtothelocalChildCareResourceandReferral(CCR&R)agency immediatelyfollowingthemonthinwhichcareisprovided. InvoicesareprocessedonthefifthbusinessdayofthemonthandonsubsequentTuesdays. Paymentsgenerallyarrivein2to3businessdaysafterprocessing. PaymentsforLCI sonlyaresenttotheparent,whoistopaythelciprovider. Ifthepaymentaddressisincorrect,thepaymentwillbesentbyreturnmailbacktothe State.AllowaminimumofaoneweekdelayforthepaymenttobereturnedtotheState, thecorrectaddresslocated,andthepaymenttober ed. FORLCPandLCI:ThisdelaycanbeavoidedbynotifyingtheCentralizedServices Providerbeforeanyaddresschange. WorkersInitials Date

22 CHILD CARE PROVIDER RIGHTS & RESPONSIBILITIES, page 2 of 4 Initials Provider s Rights FORLICENSEDANDREGISTEREDFACILITIES:Thisdelaycanbeavoidedbynotifying thelocalchildcarelicensorbeforeanyaddresschange. ADirectDepositoptionisavailabletoelectronicallytransferpaymentstoapayee sbank account. Ifaninvoiceorpaymentislate,pleasecontactthelocalCCR&Ragency. Ifanerrorinpaymentoccurs,theState/CCR&Rwillmakeadjustmentsinfuturepayments. OutstandingaccountsarereferredtotheDepartmentofPublicHealthandHumanServices (DPHHS)AccountsReceivableandtotheDepartmentofRevenue(DOR)TaxOffsetfor collection. Ifapaymentisdelayed,theEarlyChildhoodServicesBureauwillworkwiththelocalChild CareResourceandReferralagency,computersystempersonnel,andthefiscalofficeto solvetheproblemandissuethepayment. LICENSEDANDREGISTEREDFACILITIESONLY 5.Imaysetmyownpaymentratesforchildcareservices,whichmaybemoreorlessthanthe Statedistrictrates. 6.Imayrequestpaymentforholdingachildcareslotiftheslotwillbelostduringascheduled absence.theabsencemaynotlastlongerthan30daysandimustprovidealistofwaiting childrentoverifythatanotherchildwouldotherwisefilltheslot.thesamepolicymustapply toallfamilies. Please read & initial each item: Initials Provider s Responsibilities 1.Iunderstandchildcarescholarshiphoursareavailableonlyduringtheparent sapproved activities,whichmaybelessthanthemaximumlimitsindicatedonthechildcarecertification plan. 2.Iwillnotdiscriminateagainstanychildbasedonthesex,race,nationalorigin,ethnic background,religiousaffiliation,ordisabilityofthechild. 3.Iwillkeepallinformationregardingthisfamilyconfidential,exceptforthefollowing circumstances: IwillshareattendanceinformationwiththeCCR&R,withregardtoeligibilityfortheChild CareScholarshipProgram. IwillcooperatewithMontanaDepartmentofPublicHealthandHumanServicesandlocal lawenforcement,investigatingchildcarelicensingissues. Asacertified,registeredorlicensedprovider,Iamamandatoryreporterofsuspected childabuseorneglect.iwillreporttheseconcernsbycalling1(800)820kids(5437), MontanaDepartmentofPublicHealthandHumanServices ChildandFamilyServices. 4.Iwillabidebyandmaintainapplicablecertification,licensing,orregistrationrequirements (ARM ).Myproviderstatusmustbecurrentinordertoservefamiliesand receivepaymentforfamiliesreceivingchildcarescholarshipassistance. 5.FamilieseligibleforaBestBeginningsScholarshipmustchooseaproviderwhoholdsacurrent certification,license,orregistration.iwillimmediatelynotifyparentsifanegativelicensing actionaffectsmyeligibilitytoservebestbeginningsscholarshipfamilies. WorkersInitials Date

23 CHILD CARE PROVIDER RIGHTS & RESPONSIBILITIES, page 3 of 4 Initials Provider s Responsibilities 6.FORLCPandLCI:IwillimmediatelynotifytheCentralizedServiceProviderofanyaddress changes:physicaladdress,mailingaddress,orpayment(warrant)address. FORLICENSEDANDREGISTEREDFACILITIES:IwillimmediatelynotifytheChildCareLicensorof anyaddresschanges:physicaladdress,mailingaddress,orpayment(warrant)address. Apaymentdelaymayoccurifthisdoesnotoccurtimely.Thisdelaycanbeavoidedby notifyingtheappropriateagencybeforeanyaddresschange. 7.IunderstandthatIamsolelyresponsibleforanytermsofagreementsIhavewiththe parent(s). 8.IwillnotifytheCCR&Rifachildisabsentforfive(5)dayswithoutnotice. 9.Allchildcareprovidersshallmaintaincurrentsignin/signoutrecordsforeachchildreceiving childcareassistanceandutilizethemasfollows: Eachtimethechildentersorleavestheprovider'scare,theparentorotherindividual authorizedtodeliverorpickupthechildshallinitialorsignthesignin/signoutsheet.an electronicsignaturesystemmaybeusedifitemploysauniqueandconfidential identificationprocessforindividuals. Signin/signoutrecordsmustindicatethechild'sname,thedate,thehour,andtheminute whenthechildentersandleavestheprovider'scare. Theprovidershallmakesignin/signoutrecordsavailabletochildcareresourceand referralagencystaffandstateandlocalgovernmenthealth,safety,orlawenforcement representativesuponrequest. Theprovidershallkeepsignin/signoutrecordsforfiveyearsbeyondthedateofattendance. 10.Iwillclaimactualcareprovided,asdesignatedonthechildcarecertificationplanandsubject tothelimitationsofcontinuityofcarepolicies.imaynotbillforcaresubcontractedto anotherindividualorfacility. Theclaimmustindicatethechild'sactualattendanceaccurately,withinonequarterhour. Theclaimmayberoundedtothenearestquarterhouroftotaldailyattendance. Theclaimmustbeverifiablethroughtheprovider'ssignin/signoutrecordsasnoted above. 11.Asaprovider,myeligibilitytoreceivestatepaymentunderastateassistedchildcare programmaybeterminatedif: Iwillfullymisrepresentservicesprovided,withrespecttosignin/signoutrecords, attendancebilledoninvoices;or Irefuseaccesstothechildcaresettingandchildrecordsduringbusinesshourstothe followingpersonnel: o employeesorotheragentsofstateorlocalgovernment,investigatingchildcare servicesor,childabuseorneglect; o childcareresourceandreferralagencypersonnelinvestigatingchildcareservices; or o health,building,orfireofficialsinvestigatingchildcarefacilityhealthandsafety issues. 12.Childcareprovidershave60daystosubmitclaimsforservices: ImustsubmitinvoicestothedistrictCCR&Rwithin60daysoftheservicemonthtobe eligibleforpayment. Ifthechildcarecertificationplanisnotcompletedduringtheservicemonth,theinvoice, isdueatthedistrictccr&rwithin60daysfollowingtheprovider sreceiptoftheinvoice. WorkersInitials Date

24 CHILD CARE PROVIDER RIGHTS & RESPONSIBILITIES, page 4 of 4 Initials Provider s Responsibilities Ifcorrectionsoradjustmentstoaninvoicearenecessary,theymustbereceivedbythe CCR&Rwithinthe60dayperiodprescribed. 13.Whenaprovideroraparentreceiveschildcareassistanceinexcessoftheamounttowhich the provider or parent is entitled, due to a willful action of the provider or parent, the department may pursue criminal charges against the provider or parent. Criminal prosecutionmaybepursuedinadditiontorecoveryoftheoverpayment. Awillfulactionincludesbutisnotlimitedtothemakingofafalseormisleading statement,amisrepresentation,ortheconcealmentorwithholdingoffactsor information. Ifawillfulactionresultsinanoverpayment,thefollowingwilloccur: Thefirstwillfulactionwillresultina10%assessmentbeingaddedtotheamountof repaymentdueand,ifiamresponsible,copiesofsignin/signoutsheetsmustbe submittedwithinvoicesforthefollowingthreemonths. Thesecondwillfulactionwillresultina25%assessmentaddedtotheamountof repaymentdueand,ifiamresponsible,copiesofsignin/signoutsheetsmustbe submittedwithinvoicesforthefollowingsixmonths. Thethirdwillfulactionwillresultinthehouseholdorproviderresponsiblebeingineligible toparticipateinthechildcaredevelopmentfundassistance,grant,andqualitychildcare programs. LICENSEDANDREGISTEREDFACILITIESONLY 14.Iunderstandmyratesforprivatepayfamiliesmaynotbelowerthanratesforscholarship families. Rates:Thescholarshipwillreimburseatthelowerofthefollowingrates:theratesthat applytounassistedfamiliesorthestaterate. Holidays:Aregistered/licensedprovidermaychargeforcertainholidays,whenclosed,if theproviderchargesnonscholarshipfamiliesforthesameholidayobservance.billable holidaysarenewyear sday,memorialday,independenceday,laborday,thanksgiving Day,andChristmasDay. CertifiedEnrollmentDays:CertifiedEnrollmentallowsaregistered/licensedproviderto billforsomeabsences.aregistered/licensedprovidermayclaimcertifiedenrollment hours,onlyiftheproviderchargesnonscholarshipfamiliesforabsencedaysandthechild isattendingthefacilityfulltime,30+hoursperweek.achildislimitedto150cehours duringastatefiscalyear. 15.IwillreportthecurrentratesIchargenonscholarshipfamiliestotheChildCareResource& Referralagency.Theseratesareusedtofacilitatethepaymentprocessandtheyareincluded inabiennialmarketratesurvey.newratesmaybereportedontheinvoice. 16.IunderstandthatwhenIreportratechangestotheCCR&R,thenewratesmaynottakeeffect untilthefirstofthenextmonth. Provider Signature: Date: 2004, Montana Department of Public Health and Human Services WorkersInitials Date

25 HCS/CC-088 (New 11/05) STATE OF MONTANA Department of Public Health and Human Services Human and Community Services Division Legally Certified Provider and/or In-Home Care Provider Medication Administration Attestation I, acknowledge that I have discussed with the parent about (Provider) administering medication while their child or children are in my care. I, will sign the Medication Authorization form for each (Parent) prescription and non-prescription medication to be given to my child or children while in care. (Provider) I, will log the medication on the Medication Administration (Provider) Log as given to the child or children while in my care. The authority for this is MCA By signing below, I state that I have read, discussed and understand the above information. Parent Date Provider Date *Please return to the Centralized LCP/LCI Agency with your application. **Note: The provider must keep the Medication Authorization Form, Medication Administration Log and Medication Error/Incident Report on file for 3 years. 2008, Montana Department of Public Health and Human Services

26 MEDICATION AUTHORIZATION FORM TO BE COMPLETED BY PARENT Child s Name Date of Birth / / Program Name Today s Date / / *********************************************************************************** To administer a prescription medication: The medication must be in it s original container, with a legible label from the pharmacy indicating the child s name, date, name of medicine, dosage, and time, number of days medication is to be given, and expiration date of medication, doctor s/nurse practitioners name, pharmacy name and telephone number Samples must be accompanied by a doctor s written prescription Medications are to be given only to the child indicated on the label (twins and siblings can not share.) A separate authorization is required for each medication and each episode of illness Label constitutes the physicians/nurse practitioner s order Parent/Guardian is to give as many doses as possible at home. Medication: Reason for giving: Start date / / End date / / Dosage: Times to be given at child care: AM PM Last dosage was given at AM/PM Route: by mouth, skin (location), eye (R/L) On date / / Possible side effects: Special handling/storage Instructions Refrigeration Y/N Parent/Guardian Signature (required) Physician/Nurse Practitioners Signature ******************************************************************************************** Non-Prescription Medication: Parent is required to bring these medications from home. Medication must be in an original container, with child s name on the container. Medication: Health Care Provider "For children under 2, list the name of the health care provider who recommended this medication." Reason for giving: Start date / / End date / / Dosage: Times to be given at child care: AM PM Last dosage was given at AM/PM on date / / Route: by mouth, skin (location), eye (R/L) Possible side effects: Special handling/storage Instructions Refrigeration Y/N Parent/Guardian Signature (required) Unused medication: Returned to Parent Y/N or, discarded appropriately (circle one) By: Date / / *Keep in the child s file when medication is finished.