CCS - Provider 2455-Supplemental Billing Submission

Workforce Solutions Child Care Services
2002 W Loop 289 STE 117, Lubbock, TX 79407
806-744-3572 or 800-658-6284

Claiming for services not provided is FRAUD! Please do NOT submit one child at a time! There is a Click to Add Additional Children link at the bottom to give you another entry field.
Provider No*field type number
Provider Name*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Provider Phone*field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Month*field type date
PLEASE ENTER UNITS IN CAPS!
×
- Child Name*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Reason?*field type single line
  Input blocked. Maximum character limit of 4000 characters reached.
- Total Present*field type number
- Total Abs/Illness*field type number
- 01field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 02field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 03field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 04field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 05field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 06field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 07field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 08field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 09field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 10field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 11field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 12field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 13field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 14field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 15field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 16field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 17field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 18field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 19field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 20field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 21field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 22field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 23field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 24field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 25field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 26field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 27field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 28field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 29field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 30field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- 31field type single line
  Input blocked. Maximum character limit of 1 characters reached.
- P = PRESENT A = ABSENT I = ILLNESS H = HOLIDAY E = EXTENUATING CIRCUMSTANCE
Click to Add Additional Children
Provider Owner/Rep Signature*field type signature
Datefield type date
Date will be captured on form submission

CCS - Provider 2455-Supplemental Billing Submission

PLEASE ENTER UNITS IN CAPS!