Submit a Payment Adjustment Request

Providers may submit a payment adjustment request if they believe payment is missing or was issued incorrectly for authorized child care services.

Provider Statement (Required)

When submitting this request, please ensure the following information is provided:

*Provider License
*Provider Name
*Name of the authorized provider representative completing the report
*Family Case Number
*Child’s full name
*Payment cycle start date and end date
*An explanation of the payment concern

By submitting this form, you are requesting a review of child care payments you believe are missing or incorrect. All requests are subject to review and verification.

Provider Details

Child Care Regulation Licensing No

Enter Your License Number

Name of Facility

Authorized Representative

Name of Authorized Provider Representative

Authorize Rep Phone Number

Authorized Rep Email

Family Details

Parent's Full Name

Family Case Number

Child(ren) Full Name(s)

Payment Dates

Payment Start Date

Payment End Date

Adjusted Requested Amount

Comment

Reason for Payment Inquiry

More Details / Comment

I understand that Payment Inquires must be submitten within 45 days of origional payment.

Provider Submit Within 45 Days

I certify that the information provided is accurate to the best of my knowledge.

ProviderCertification

Supporting DocumentationYou can upload a maximum of 1 file, up to 48MB. Supported files include image, .doc, .dot, .wbk, .docx, .docm, .dotx, .dotm, .docb, .xls, .xlt, .xlm, .xlsx, .xlsm, .xltx, .xltm, .ppt, .pot, .pps, .pptx, .pptm, .potx, .potm, .ppam, .ppsx, .ppsm, .sldx, .sldm, .pdf.

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After Submission

After submission, your inquiry is forwarded to our team and assigned to a dedicated Payment Coordinator who will begin processing it.

Processing

Our support team aims to respond to all payment inquiries within 48 hours. For urgent matters, please contact our hotline directly.

Confirmation

Providers may receive confirmation once the Pay Rate has been updated, or contacted if additional information is needed

​​Submit a Payment Adjustment Request

​​​​​Provider Details

Authorized Representative

Family Details

Payment Dates

Comment

I understand that Payment Inquires must be submitten within 45 days of origional payment.

I certify that the information provided is accurate to the best of my knowledge.

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After Submission

Processing

Confirmation

Submit a Payment Adjustment Request

Provider Details

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