DCC-97 Provider Billing Form

To receive a DCC-97, Provider Billing Form (PBF) or for a child to show up on a PBF in the portal, the DCC-94 (certificate) must be signed by the provider and parent then returned to the DCBS office or provider portal within ten (10) calendar days. Once returned a Family Support worker will change the enrollment from pending to active in the system. Changing the enrollment from pending to active will signal to the system to send out a DCC-117, Enrollment Approval Notice to the provider.

Return the ENTIRE 3-page Certificate by:

Upload to the KICCS Provider Portal (fastest and most efficient)
Parent upload to Kynect.ky.gov (fastest and most efficient)
Fax to 502-573-2007 (keep the fax transmission sheet for verification of dates and success of transmission):
Hand deliver to the local DCBS office
Mail to:
DCBS
PO Box 2104
Frankfort, KY 40603

Keeping a copy of all pages of the certificate for the provider’s records is useful if the certificate is lost in the mail or not all pages are received through the fax. Retaining a copy of the fax transmission sheet to guarantee number of pages faxed, date, and time faxed is also advisable.

Allowing children to begin receiving care without a signed certificate is a business decision the provider may make.
Please remember, CCAP payments are not guaranteed until a certificate has been signed, returned to the DCBS office, entered in to the system (which completes the enrollment process) and a DCC 117 Provider Enrollment Approval Notice has been received.