Get Jcc Provider Information Form - Florida's Center For Child Welfare

Completing the JCC Provider Information Form is a critical step for providers working with Florida's Center For Child Welfare. This guide will walk you through each section of the form, ensuring you can accurately fill it out online with confidence.

Follow the steps to effectively complete the form

1. Select the ‘Get Form’ button to access the JCC Provider Information Form and open it for online completion.
2. Begin by entering your certificate number and vendor number in the designated fields at the top of the form.
3. In the 'Provider Name' section, clearly write the name of the provider or organization. Then, input either your Federal ID number or Social Security number as required.
4. Fill in the street address along with any apartment number, followed by the city, state, zip code, and phone number.
5. Provide the contact person's name. This should be someone who can be reached regarding the services provided.
6. In the 'Parent's Name' field, enter the name of the parent or guardian. Additionally, include their Social Security number.
7. List the names of the children currently in your care if applicable. This section is meant solely for in-home care providers.
8. For each child in your care, complete the section regarding their agreed daily rates and schedules. Fill in the name, schedule, approved rate, and parent fee for up to four children.
9. Indicate your relationship to the children by checking the appropriate option. Choose one based on whether you are a relative, legally exempt from licensing, or a licensed provider.
10. Input the effective dates of service to specify the duration for which you will provide care.
11. Ensure both the provider and the parent sign and date the form to validate the information. Collect any necessary signatures.
12. Finally, verify that all information is accurate and complete. Save your changes, then proceed to download or print the form if required. You can also share it as needed.

Complete and submit your JCC Provider Information Form online today to ensure timely processing.