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DCC-94 – Child Care Service Agreement and Certificate Copy

When child care enrollment is added to an approved CCAP case, a DCC-94 Child Care Service Agreement and Certificate will be sent to the parent and the provider IF the parent granted Provider Portal access during the interview process. The DCC-94 (Certificate) shows the child’s pending enrollment, along with other valuable information.

DCC-94 Child Care Service Agreement and Certificate. Click each page to View Larger.

Please review certificates for:

  • Child’s schedule
  • State reimbursement rate
  • Provider payment
  • Family copay
  • Start and end date of enrollment
  • A provider needs to be aware of the child’s eligibility end date on the certificate because a notice will not be sent when the end date is nearing. An enrollment that does not have any changes during the 12-month eligibility period uses the dates on the certificate as notice of end of care. A DCC-94C, Provider Notification Letter is only sent 10 days prior to an enrollment ending if the enrollment is ending during the 12-month certification period.

Before signing the certificate

Before signing the certificate, discuss with the Parent:

• Enrollment start/end date
• Enrollment schedule
• Copay amount to be paid weekly
• Overage amounts (difference between the State Max Rate and what the center charges daily. Overages are not printed on the form as they are unique to each child care center)

Please make sure the start date and the child’s schedule are correct before signing the certificate. Signatures mean both parties agree that the information printed on the certificate is accurate and correct. If the information is incorrect, do NOT sign the certificate. It is the parent’s responsibility to contact Family Support for corrections. DCC/CCAP staff cannot correct a certificate.

The certificate must be signed (not electronically) by the provider and client and returned to DCBS Family Support or uploaded to the Provider Portal within ten (10) calendar days of being generated. Payments cannot be made until the signed certificate is returned. It is the responsibility of the parent and the provider to make sure the certificate is returned.

  • If the client has questions about the certificate, the client will need to call, (855) 306-8959 or visit a DCBS Family Support office.
  • If you, as the provider, have questions about the certificate email CCAPProviderPayments@ky.gov or call DCC at (844) 209-2657. When contacting DCC be prepared to provide your license number, the case number, and a brief description of the issue.

DCC-97 Provider Billing Form

In order 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 Service Agreement and 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.

Return the ENTIRE 3-page Certificate by:

  • Upload to the KICCS Provider Portal (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 the date and time faxed is also advisable.

DCC-97 Provider Billing Form (PBF). Click each page to view larger.


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, and entered into the system which completes the enrollment process.