CMS-07-021/023 - Los Angeles County Department of Children and ...

PAYMENT RESOLUTION NOTIFICATION
INSTRUCTIONS:
Complete one request per minor
FAX to the DCFS Payment Resolution Unit at (626) 691-1136
Mail to Revenue Enhancement at 725 S. Grand Ave., Glendora CA 91740
An annotated copy will be returned for your records when the payment discrepancy is resolved
VENDOR INFORMATION PAYMENT DISCREPANCY
Date of Request Payment Months in question
Vendor or Name
Vendor Number
Contact Person
Telephone Number
Child’s Name
Child’s Birth date
Child’s Case Number
CHILD’S INFORMATION
PLACEMENT INFORMATION
To expedite your payment request please answer the following
information:
The child was placed by: DCFS Probation
Did you receive a Blue Placement Packet from the CSW?
YES NO
Have you ever received a payment for this child?
YES NO
Did you send in a voucher for requested payment?
YES NO
Rate Amount: _____________________________________
Beginning Date of Placement: ________________________
Ending Date of Placement: __________________________
Incorrect rate
Birth date rate change
First payment was not received
Start date discrepancy
Stop date discrepancy
Clothing Allowance
Other payment problems
EXHIBIT M
RESOLUTION/COMMENTS
Completed by DCFS Staff
Eligibility Worker: Date:
Telephone Number: