How Payment Is to Be Released
Medical / Dental Services
NOT for Orthodontics
You must complete separate requests for each child.
You must use “TAB” key to move from one field to the next.
Hint: Use “X” key to check a box (without having to use your mouse)
Hint: Use “F4” key to drop the list in a dropbox, then type the FIRST letter of your choice to fill.
Medical/Dental services and purchases must be pre-approved whenever possible. Unless the situation is an unavoidable emergency, pre-approval from the Special Funds Unit must be obtained.
“PLANS” for Medical/Dental services are approved PRIOR to services starting and billed later.
The approval is copied and routed to the SW, and the Service Provider.
Service providers are instructed to bill the Special Funds Unit directly. Monthly billing is preferred.
If the Special Funds Unit does not receive a bill within 6 months from the date of approval, the “PLAN” will be voided. Further, if more than 6 months lapses between billings, the unbilled portion of the “PLAN” will be voided.
It is very important for the SW to be aware that once the case is closed, and in some situations once parental rights are terminated, DFCS Special Funds will no longer pay for services, even if there are still sessions remaining on the “PLAN”.
Fiscal Services requires a W-9 be on file for each vendor at the time of payment. The County has over 20,000 vendors on file. To check to see if a W-9 is already on file, Contact Mary Beth Rogers 975-5680 or Alana Rainville 975-5791.
"Double Click Here to Begin"
Filing: 3rd Fastener, Left - Top Medical / Dental Services SCZ414Z.doc
Page 1 of 3 DFCS Request 07/06
Santa Clara County
Social Services Agency
Department of Family and Children’s Services
Medical / Dental Services
SW Name / SW # / Phone #Case Last Name / Case First Name / County Case # (State)
Check service category.
ER DI IS FMC FMV FRC FRV PPC PPV
Check description(s) of the case.
The child(ren) is in the home.
The child(ren) is out of the home.
The child(ren) needs to be placed with a relative/NREFM and these items are necessary for successful placement.
The child(ren) is placed with a relatvie/NREFM and these items are necessary to maintain the placement.
Answer all of the questions in this section.
Yes No Is this child(ren) eligible for FOSTER CARE PAYMENTS from either AFCD or CalWORKs?
Total # of Children on this case:
Yes No The child is in the home and is at risk of being removed from the home without these services.
Yes No The child is out of the home and could probably be returned home safely with these services.
Yes No The child would benefit and the case plan goals would be supported by these services.
Yes No There is a financial need which necessitates expenditure of DFCS funds. (To determine if there is a “Financial Need”, the Social Worker must consider both Birth Parents’ income, and the resources of the placement family including whether or not the service/purchase requested is covered by any special rates the placement family is receiving.)
PERSONS BEING REFERRED FOR SERVICES ON THIS REQUEST
Child Last Name / First Name / DOB / Placement TypeHome w/ParentNew Relative HomeExisting Relative HomeNew NREFM HomeExisting NREFM HomeCounty Licensed Foster HomeProspective Licensed Foster HomeLicensed Foster Home Cap IncreaseFFAGroup HomeLegal GuardianOther:
InFORMATION for this request
Amount requested:Describe the items to be purchased or services requested. If this is an emergency reimbursement request, please describe why it was an emergency too.
Medical/Dental Coverage Check all that apply.
Child(ren) does not have MediCal.
Child(ren) has MediCal, but it does not cover this need. Why not:
Child(ren) does not have private health insurance coverage.
vendor/PAYEE information
Name (as it is to appear on check) / Contact Person / PhoneStreet Address / City / State / Zip / FAX
Be sure the this information is correct in order to avoid confidential
information from being given to the wrong person(s).
Check to be made to: (Checks are usually made to the Vendor unless there is an emergency.)
Vendor Client Parent/Placement Provider (Foster Parent, Relative, NREFM, Group Home, etc.)
You must indicate which procedure will be followed:
This was an EMERGENCY which needs to be reimbursed.
The Vendor will accept a “Plan” for services, then bill DFCS after services have been rendered. (For this option, the
Check is mailed directly to the vendor by Accounts Payable.)
The Vendor requires payment at the time of service. The date(s) of service is/are: . (For this option, a week is
required to prepare the check(s). The Special Funds Analysts will pick up each Check from Accounts Payable and
call the Social Worker when ready.)
REQUIRED ATTACHMENTS
W-9 required if one is not already on file.
Estimate of cost and diagnosis or receipt (receipt required for emergency purchases or treatment for which pre-authorization was not possible).
REQUIRED SIGNATURES
Signature of Social Worker / DateSignature of Social Work Supervisor / Recommended for: / Date
Approval Denial
Signature of Social Services Program Manager / Recommended for: / Date
Approval Denial
FUNDING AND ROUTING INFORMATION
It is County Ordinance that all requests MUST be approved PRIOR to expenditure of funds or receipt of services.
Obtaining a check requires 5 working days. Anything less is considered a RUSH request and will be considered on a case-by-case basis. Please write “RUSH” on the top of this form.
Contact Person: Special Funds Desk, Mary Beth Rogers 975-5680 and Alana Rainville 975-5791.Routing: SW SWS SSPM Special Funds Desk.
All approvals will be copied to the SW.
All denials will be returned to the SW with denial information in writing.
Filing: 3rd Fastener, Left - Top Medical / Dental Services SCZ414Z.doc
Page 1 of 3 DFCS Request 07/06