Ocfs Ldss 4699 Form – Fill Out and Use This PDF

OCFS-LDSS-4699 (Rev 6/2011)

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NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

ENROLLMENT FORM FOR PROVIDER OF LEGALLY-EXEMPT

FAMILY CHILD CARE AND LEGALLY-EXEMPT IN-HOME CHILD CARE

Child Care providers who are not required by NYS law to be licensed or registered to operate a day care program use this form to enroll with a legally‐exempt caregiver enrollment agency to provide subsidized child care.

Instructions: Please use black/blue pen.

 Provider: Complete the “Child Care Provider Section” of this form.

 Parent/caretaker: Complete the “Parent Information Section” of this form.

 The provider and parent/caretaker walk though and inspect the site, review sections of the form, then sign and date where indicated.

Submit the completed form to the enrollment agency serving the location where the child care is being provided.

I. CHILD CARE PROVIDER SECTION

A . C H I L D C A R E P R O V I D E R A N D P R O G R A M

1.Child Care Provider Name:

Mr. Mrs. Ms.

Last

First

MI

Suffix

Other names known by:

Maiden, married, aliases, etc.

2.Identifying and Contact Information:

Enrollment Number:				Site Phone: (	)		 Listed	 Unlisted
		(If Applicable)
Date of Birth:	/	/		Home Phone: (		)	 Listed	 Unlisted
	(mm/dd/yyyy)
Gender (M or F):				Cell Phone: (		)
Social Security # 1:				E-Mail Address2:			 No E-Mail Address

3.Child Care Location: Give address where child care is provided.

House Number	Street			Apt.
Address Line 2				Floor
City		State	Zip	County

4.Home Address: Is your home address the same as the child care location given above?

 Yes.  No. If No, give address below.

	House Number	Street				Apt.
	Address Line 2					Floor
	City		State	Zip	County
(For Enrollment Agency Use)			(For Local District Use)			WMS
Received Date: ___________			Parent’s Case No.:_______________________ Type: Local
Complete Date:			LSSD Office/Unit/Wkr. No.:		/	/

1The social security number is required when the local social services district issues child care subsidy payments directly to a child care provider. Failure to provide the social security number may delay payment. The social security number of provider is optional when a local social services district issues child care subsidy checks to the subsidy recipient (parent/ caretaker). If the social security number is provided, it may be used by

federal, State and local agencies for federal reporting, to prevent the duplication of services and to prevent fraud. 2 The E-mail address if given may be used by the enrollment agency to contact you.

OCFS-LDSS-4699 (Rev 6/2011)Page 4 of 16

D . O T H E R Q U A L I F I C A T I O N S & P R O G R A M C H A R A C T E R I S T I C S

1.PROVIDER’S ELIGIBILITY FOR ENHANCED RATE BASED ON TRAINING

Have you completed in the past 12 months, 10 hours of training aimed at improving the quality of the care you provide?

Yes. If Yes, you may be eligible to receive an enhanced rate. ATTACH the OCFS-LDSS-4699.3- Legally- Exempt Child Care Provider Training Record and your training certificates.

No.

2.FEDERAL FOOD PROGRAM ASSISTANCE

The Child and Adult Care Food Program (CACFP) helps Family Child Care programs to pay for meals and snacks served to child(ren) in care. Are you currently participating in CACFP?

A) No. If you want information about CACFP call: 1(800) 942-3858.

B) Yes. If “yes”, provide information about your participation in CACFP and ATTACH proof of your participation dated within the past 12 months below:

1)Sponsor Agency Name: _____________________________________________

2)Sponsoring Agency ID Number (if known): _______________________________________

3)Your CACFP Provider Number:________________________________________

4)Agreement Number: ________________________________________________

	5) Proof of Participation:	Type of Proof: (Check  below to show proof attached)
	Date on Proof:_____________	CACFP Claim Reimbursement Stub
		CACFP Monitoring Checklist (DOH-4118)
		CACFP Continuous Application and Agreement (DOH-3705)

3.AMOUNT YOU CHARGE

Do you charge parents receiving subsidy the same amount that you charge parents for non-subsidy child(ren) of the same age and similar care?

A) Yes.

B) No. If, No choose the statement below which describes the amount you charge.

1) I charge parents receiving subsidy less than I charge other parents.

2) I charge parents receiving subsidy more than I charge other parents.

4.ADMINISTRATION OF MEDICATION

NYS Law restricts the right to administer medication other than over-the-counter topical ointments, sunscreen and topically applied insect repellent to specific medical professionals who are authorized by NYS to administer medication. Some individuals are exempt from this requirement based on their relationship to the child, family, or household and are permitted to administer medications, including:

The child’s parent/caretaker, step-parent, legal custodian, legal guardian, or member of the child’s household,

A child care provider employed by the parent/caretaker to provide child care in the child’s home,

Family members who are related within the 3rd degree of consanguinity to the child’s parent or step parent. This includes the child’s grandparent, great-grandparent, great-great grandparent, aunt/uncle (and spouse), great aunt/uncle (and spouse), first cousin (and spouse), and brother /sister.

Child care providers who are trained and authorized by the Office of Children and Family Services (OCFS)

under the Health Care Plan for Administration of Medication, approved by a qualified health care consultant, and who are:

OOperating in compliance with the NYS regulation which includes receiving training on medication administration,

OAuthorized by the child’s parent/caretaker, step parent, legal guardian, or legal custodian to administer medication, and

OAdministering medication to subsidized children in care.

To receive OCFS authorization to administer medication, a child care provider must be at least 18 years of age and literate in the language in which the parental permissions and health care provider’s instructions will be given. Any person who is NOT AUTHORIZED by NYS Law or NOT EXEMPT from this legal requirement, may ONLY administer over-the-counter topical ointments, sunscreen and topical insect repellent. Examples of medication they MAY NOT ADMINISTER include, but are not limited to: Tylenol, Ritalin, insulin, antibiotics, and ear, eye, or nose drops.

OCFS-LDSS-4699 (Rev 6/2011)

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A)Are you, your employees or volunteers LEGALLY PERMITTED to administer medication to child(ren) in subsidized care?

Check  all statements that apply to you. Provide all other information as it applies.

1) Yes. I am RELATED within the 3rd degree by blood or marriage to the child(ren)’s parent or step-parent. Therefore, I am allowed to administer medication to the child(ren) following the health care provider’s instructions and when I have appropriate permission from the parent.

I am grandparent of:

I am great-grandparent of:

I am great-great-grandparent of:

I am aunt/uncle of (includes spouse) of:

I am great aunt/great uncle (includes spouse) of:

I am first cousin (includes spouse) of:

I am brother/sister of:

2) Yes. I am PROVIDING CARE IN THE HOME of the following child(ren): ___________________

_____________________________________________________________________. Therefore, I am

PERMITTED to administer medication to these children when I have appropriate permission from the parent and I am following the health care provider’s instructions.

3) Yes. I am a NYS medical professional AUTHORIZED BY NYS DEPARTMENT OF EDUCATION (NYSED) to administer medication. Therefore, I am allowed to administer medication to child(ren) in my care when there are appropriate permissions from the parent and when following the health care provider’s instructions.

a) My profession is (check  one):

Registered Nurse

Nurse Practitioner

Physician Physician Assistant

b) License number: ________________________

I have attached a copy of my current NYS professional medical license. (Required).

4) Yes. I HAVE a Health Care Plan for the Administration of Medication (OCFS-LDSS-7000) approved within the past 2 years. Therefore, the qualified medications administrant named below is AUTHORIZED BY OCFS to administer medication to subsidized children in my care according to the health care provider’s instructions and when there are appropriate permissions from the parent.

a) Plan approval date: _____________________

I have attached a copy of the first page AND the approval page of my Health Care Plan for the Administration of Medication (OCFS-LDSS-7000).

b)Name of the qualified Medications Administrant: _________________________________.

c)Health Care Consultant (HCC) name: __________________________________________.

d)Health Care Consultant Profession (check  one):

Registered Nurse

Nurse Practitioner

Physician

Physician Assistant

e) License Number: _________________________________.

5) No. None of the above permissions apply to me. I am not authorized by OCFS or NYSED. I understand I cannot administer medication to the child(ren) in care, except: Over-the-counter topical ointments, sunscreen, and topically applied insect repellent.

B) Are you interested in seeking authorization to administer medication to child(ren) in subsidized care?

Yes. I want to learn how to start the process. Please send me the OCFS-LDSS-7007, Obtaining Authorization to Administer Medication to Children in Legally-Exempt Care.

No. I will not be seeking authorization to administer medication at this time.

C)I agree I will administer medication in compliance with NYS Law and only to the extent that I am permitted by NYS Law which I have indicated by my choice on this page above.

Yes.  No.

D)If I have employees or volunteers, I will make sure that each of my employees and volunteers administers medication in compliance with NYS Law and only to the extent permitted by NYS Law.

Yes.  No.