Detail System Design - Illinois Department of Human Services



Appendix F – Forms information

This Appendix lists information related to forms including the frequency the form is generated and how it’s accessed, whether a Spanish version is available, the outgoing form type, and whether conversion to a PDF is needed.

*All forms that are outgoing from CCMS are system recognizable when incoming. For forms that are incoming only, it is specified in the table below whether they should be system recognizable.

|Form name |Frequency/ Access |Spanish version |Form Type - Outgoing |Need conversion to |

| | |available? | |PDF? |

|Eligibility |

|IL444-3455 - Child Care Application |N/A |Yes |Blank PDF (potentially |No |

| | | |barcoded for document type) | |

|IL444-3455E - Child Care Redetermination |Both |Yes |Barcoded |No |

|IL444-3455G - Request for a Child Care Provider |On-demand daily |Yes |Barcoded |No |

|Change | | | | |

|Change of Information |On-demand daily |Yes |PDF |No |

|IL444-4480 Request for Additional Information |On-demand daily |Yes |Barcoded- potentially |No |

| | | |dynamic | |

|IL444-3514 (N-1-11) Wage Verification |On-demand daily |Yes |Blank PDF (potentially |No |

| | | |barcoded for document type) | |

|IL444-4339 – Request for Provider Address Change |On-demand daily |Yes |Barcoded |No |

|Information | | | | |

|IL444-3455A (R-6-03) - Approval of Request for |On-demand daily |Yes |N/A |No |

|Child Care Payments |Local Print and Mass | | | |

| |Mailing | | | |

|IL444-4178 (R-01-02) – Notice of Cancellation of |On-demand daily |Yes |N/A |No |

|Child Care Payments |Local Print and Mass | | | |

| |Mailing | | | |

|IL444-4179 (N-9-98) - Denial of Request for Child |On-demand daily |Yes |N/A |No |

|Care Payments |Local Print and Mass | | | |

| |Mailing | | | |

|IL444-4587 (N-01-01) – Notice of Cancellation of |Monthly |Yes |N/A |N/A |

|Child Care Payments for Child Age 13 | | | | |

|IL444-4590 (N-7-01) - Notice of Provider |On-demand daily |Yes |N/A |No |

|Cancellation From Child Care Case (Provider |Local Print and Mass | | | |

|Closeout) |Mailing | | | |

|Eligibility - LINK ONLY |

|IL444-3461 License Exempt Child Care Center |N/A |No |Link but recognizable |No |

|Self-Certification (Draft 9-07) | | |incoming | |

|IL444-2790 – Self-Employment Record |N/A |Yes |Link but recognizable |No |

| | | |incoming | |

|IL444-3455F – Request for Reimbursement |N/A |Yes |Link |N/A |

|IL444-4469 – Child Care Rate Certification Form |On-demand daily Local|Yes |Link but recognizable |No |

| |Print Only | |incoming | |

|W-9 Form |N/A |Yes |Link but recognizable |N/A |

| | | |incoming | |

|IL444-3455B (R-8-07) – Important Parent |N/A |Yes |Link. User populated PDF |No |

|Co-Payment Information | | |template | |

|IL444-4341 (R-4-07) – Child Care Payment Rates for|N/A |No |Link. User populated PDF |No |

|Child Care Centers | | |template | |

|IL444-4343 (R-4-07) – Child Care Payment Rates for|N/A |No |Link. User populated PDF |No |

|Home Based Child Care Providers | | |template | |

|IL444-4773 Child Care Telephone Billing Agreement |On-demand daily Local|Yes |Link but recognizable |No |

| |Print Only | |incoming | |

|IL444-4003 Responsibility and Service Plan |N/A |N/A |Incoming only, recognizable |N/A |

|IL444-2151 IDHS Referral |N/A |N/A |Incoming only, image |N/A |

|IL444-2151A Contracted Provider's Referral |N/A |N/A |Incoming only, image |N/A |

|IL444-2151D Teen Parent Progress Report Form |N/A |N/A |Incoming only, image |N/A |

|IL444-3085 IDHS Contract Report Notification of |N/A |N/A |Incoming only, image |N/A |

|Employment | | | | |

|Child Care Telephone Billing System Notice |N/A |N/A |Link |N/A |

|Child Care Telephone Billing Practice Licensed | | |Link | |

|Home | | | | |

|Child Care Telephone Billing Practice |N/A |N/A |Link |N/A |

|Licensed-Exempt Home | | | | |

|IL444-0800 Illinois Debit MasterCard Payment |N/A |N/A |Link |N/A |

|Option Form | | | | |

|Customer Service |

|IL444-4194 (R-1-11) Authorization for Background |On-demand daily |Yes |Barcoded |No |

|Check | | | | |

|3522 Relative Background Check Letter (Change |On-demand daily |Yes |Barcoded |No |

|Order 49649) | | | | |

|3523 Non-Relative Background Check Letter (Change |On-demand daily |Yes |Barcoded |No |

|Order 49649) | | | | |

|Child Abuse and Neglect Tracking System (CANTS) |On-demand daily Local|No |Barcoded |No |

|Batch Routing Document |Print Only | | | |

|IL444-1900 (R-10-09) Overpayment Referral Form |On-demand daily Local|No |User populated PDF template,|No |

| |Print Only | |recognizable incoming | |

|3518 Overpayment Calculation Sheet |On-demand daily Local|Yes |N/A |No |

| |Print Only | | | |

|IL444-3520 (N-1-11) Child Care Overpayment Letter |On-demand daily Local|Yes |User populated PDF template |No |

| |Print Only | | | |

|IL444-3519 (N-1-11) Provider Overpayment Letter |On-demand daily Local|Yes |User populated PDF template |No |

| |Print Only | | | |

|IL444-3515 (N-1-11) Parent Overpayment Change |On-demand daily Local|Yes |User populated PDF template |No |

|Letter |Print Only | | | |

|IL444-3517 (N-1-11) Provider Overpayment Change |On-demand daily Local|Yes |User populated PDF template |No |

|Letter |Print Only | | | |

|IL444-3516(N-1-11) Rescind of Overpayment |On-demand daily Local|Yes |User populated PDF template |No |

| |Print Only | | | |

|Customer Service - LINK ONLY |

|4338 Attendance Exemption Request Form (12-2000) |N/A |No |Link |No |

|IL444-0102 (R-8-03) – Statement of Facts |N/A |Yes |User populated PDF template,|No |

| | | |recognizable incoming | |

|IL444-0065 – Request to Withdraw Appeal |N/A |No |User populated PDF template,|N/A |

| | | |recognizable incoming | |

|IL444-0103 – Notice of Appeal |N/A |Yes |N/A |N/A |

|IL444-1456 Implementation of Appeal Decision |N/A |No |User populated PDF template |No |

|4289 Request to Establish Accounts Receivable |N/A |No |Blank PDF |No |

|3521 License Exempt Center Background Check Letter|N/A |No |N/A |N/A |

|PIQA |

|First Non Compliance Letter (Report) |On-demand daily Local|No |User populated PDF template |No |

| |Print Only | | | |

|Second Non Compliance Letter (Report) |On-demand daily Local|No |User populated PDF template |No |

| |Print Only | | | |

|Final Notice of Non Compliance (Report) |On-demand daily Local|No |User populated PDF template |No |

| |Print Only | | | |

|Child Care Fraud Referral Form |On-demand daily Local|No |Barcoded |No |

| |Print Only | | | |

|Monitoring Template |On-demand daily Local|No |N/A |N/A |

| |Print Only | | | |

|Child List by Provider |On-demand daily Local|No |User populated PDF template |New |

| |Print Only | | | |

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