Celebrating 45 Years of Service to the Community.

LCDJFS - Provider Documents



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Absent policy JFS 01242 Medical Dental Emergency Plan
Sample - Blank Activity Plan - Infant JFS 01261 Manual Claim Form
Sample - Blank Activity Plan - Toddler JFS 01261-1 Manual Claim Form instructions
Sample - Blank Activity Plan - Preschool JFS Medical Statement for Type B Providers   
Sample - Blank Activity Plan - School Age JFS 01292 Request for Payment Adjustment
Sample - Child Information form JFS 01292-1 Request for Payment Adjustment instructions
Sample - Child Medical Statement JFS 01297 Child Health and Enrollment Form
Sample - Complete Activity Plan - Young Infants JFS 01297 Child Health and Enrollment Form
Sample - Complete Activity Plan - Mobile Infants  JFS 01299 Incident and Injury Report  
Sample - Complete Activity Plan - Toddler JFS 01302 Request for Child Abuse and Neglect Report Information
Sample - Complete Activity Plan - Preschool   JFS 01329 Non-Conviction Statement
Sample - Complete Activity Plan - School Age JFS 01332 Child Care Handbook for Caretakers
Sample - Fire Drill Report 2014 JFS 01332-1 Instructions for Completing JFS 01332
Sample - Health Alert Form JFS 01528 Type B Provider Employee Record Chart
Sample - Ohio Learning and Development Standards documentation      JFS 01634 Caretaker Provider Agreement
Sample - Permission to Photo JFS 01643 Application for Licensed Type B Home
Sample - Professional Development Plan - Self Assessment JFS 01644 Permission to Administer Medication
Sample - Routine Field Trip Permission JFS 01923 Emergency Substitute Caregiver Statement
Sample - Swimming Permission JFS 01926 Inspection Report
Sample - Web Worksheet - with Learning Centers JFS 01930 Sleep Position Waiver Statement
LCDJFS Delinquent Family Fee Form 8-13 JFS 01933 Liability Insurance Statement
LCDJFS Link Up Request Form 8-13 JFS 08087 Communicable Disease Chart
LCDJFS Professional Pay Rates
LCDJFS Termination Notice 8-13


New documents (2-15):
LCDJFS Notice of Child Enrollment
LCDJFS Notice of Termination of Provider Services
LCDJFS Notice of Delinquent Copayment
LCDJFS Notice of Written Agreement for Payment of Copay

New documents (5-15):

JFS 01928 Medical Physical Care Plan
JFS 01305 Child Medical Statement