Get Form 04cb002e (dcys-s-2) - Oklahoma Department Of Human ... - Okdhs

Filling out the Form 04CB002E, also known as the CFSD Claim for Purchase of Residential Care, is a critical step for billing the Oklahoma Department of Human Services for residential services provided to youth in custody. This guide will assist you in completing the form correctly and efficiently online.

Follow the steps to fill out the Form 04CB002E accurately.

1. Click the ‘Get Form’ button to obtain the form and open it for completion in the online editor.
2. Enter the month and year for the services claimed in the designated field.
3. Input the federal employer identification number (FEI) of the facility that provided the services.
4. Enter the contract number under which the services were rendered.
5. Provide the name of the facility delivering the services.
6. Fill in the eight-digit OKDHS KIDS assigned case number of the youth receiving services.
7. Write the exact case name of the youth, using the format: last name, first name, and middle initial.
8. List the residents in alphabetical order, ensuring all claims are complete and accurate to avoid delays.
9. Enter the appropriate medical number and person code for the youth.
10. Input the Medicaid client ID number assigned to the client.
11. Specify the dates of service by entering the first and last day of the month, or exact dates of placement.
12. Calculate and enter the total leave days taken by the youth during the month.
13. Enter the total number of days for which services are claimed for the youth.
14. Indicate the actual leave status dates of the youth by marking them appropriately.
15. Enter the number of non-utilized days for the beds.
16. Calculate the total days claimed for all youth provided services.
17. Input the daily rate at which services are claimed in the X rate field.
18. Finally, calculate and enter the total amount claimed based on total days multiplied by the rate.
19. Once all fields are filled out, review the information for accuracy before saving changes, downloading, printing, or sharing the form.

Take the next step by completing and submitting your Form 04CB002E online today.