Form FS-334B "Respite Provider Services & Associated Mileage Reimbursement" - Vermont

What Is Form FS-334B?

This is a legal form that was released by the Vermont Department of Children and Families - a government authority operating within Vermont. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2017;
  • The latest edition provided by the Vermont Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FS-334B by clicking the link below or browse more documents and templates provided by the Vermont Department of Children and Families.

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Download Form FS-334B "Respite Provider Services & Associated Mileage Reimbursement" - Vermont

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RESPITE PROVIDER SERVICES & ASSOCIATED MILEAGE REIMBURSEMENT
Invoice# (optional)_________
NAME:
ADDRESS
PROVIDER'S SOCIAL SECURITY NO:
Signature:
(social and signiture are required for payment)
FAMILY/
TOTAL
NUMBER
DATE OF
CHILD
START
END
PAYMENT
MILEAGE DETAIL
OF
(EX.WATERBURY - BARRE & RETURN)
RESPITE
NUMBER
NAME OF CHILD
TIME
TIME
AMOUNT
MILES
Total number of Miles
0.00
Mileage Rate:
Total Dollar Amount
$ 0.00
$ 0.00
for Respite
Total Amount for Mileage
$ 0.00
Grand Total
Respite care must be pre-approved. Two methods of reimbursement are acceptable.
1. Foster parent has paid the provider, foster parent will fill out this form and attach a receipt from the provider .
(example: I Mary Doe provided respite care for Joey Smith on 1/3/2017. I received $20.00 from Sally Smith for this service.
2. Provider can bill DCF directly for services. (note by billing directly you are stating you have not been paid by any other source.)
DISTRICT OFFICE USE ONLY:
NO
LICENSED FOSTER PARENT:
YES
CHILD INFORMATION:
IN CUSTODY (USE RESPITE CODE BELOW)
OPEN FAMILY CASE (USE RESPITE CODE BELOW)
NO OPEN CASE (USE FAMILY PRES CODE BELOW)
BUSINESS OFFICE USE ONLY:
Date:
APPROVAL SIGNATURE:
Dept ID
Account Code: 603230(TRANSPORTATION)
603110 (RESPITE) 603060/603061 (FAMILY PRES)
Program Code:
FS - 334B R 7.2017
RESPITE PROVIDER SERVICES & ASSOCIATED MILEAGE REIMBURSEMENT
Invoice# (optional)_________
NAME:
ADDRESS
PROVIDER'S SOCIAL SECURITY NO:
Signature:
(social and signiture are required for payment)
FAMILY/
TOTAL
NUMBER
DATE OF
CHILD
START
END
PAYMENT
MILEAGE DETAIL
OF
(EX.WATERBURY - BARRE & RETURN)
RESPITE
NUMBER
NAME OF CHILD
TIME
TIME
AMOUNT
MILES
Total number of Miles
0.00
Mileage Rate:
Total Dollar Amount
$ 0.00
$ 0.00
for Respite
Total Amount for Mileage
$ 0.00
Grand Total
Respite care must be pre-approved. Two methods of reimbursement are acceptable.
1. Foster parent has paid the provider, foster parent will fill out this form and attach a receipt from the provider .
(example: I Mary Doe provided respite care for Joey Smith on 1/3/2017. I received $20.00 from Sally Smith for this service.
2. Provider can bill DCF directly for services. (note by billing directly you are stating you have not been paid by any other source.)
DISTRICT OFFICE USE ONLY:
NO
LICENSED FOSTER PARENT:
YES
CHILD INFORMATION:
IN CUSTODY (USE RESPITE CODE BELOW)
OPEN FAMILY CASE (USE RESPITE CODE BELOW)
NO OPEN CASE (USE FAMILY PRES CODE BELOW)
BUSINESS OFFICE USE ONLY:
Date:
APPROVAL SIGNATURE:
Dept ID
Account Code: 603230(TRANSPORTATION)
603110 (RESPITE) 603060/603061 (FAMILY PRES)
Program Code:
FS - 334B R 7.2017