CCMS Forms Job Aid

The purpose of this job aid is to provide information on documents that can be generated using CCMS.

Note: If an * displays next to the Document Name, this means when this form is received into CCMS, the document type from the form is available on the Validate Documents page. If a ** displays next to the Document Name, this means when this form is received into CCMS, the document type, county, case name/number, and provider number/type from the form are available on the Validate Documents page.

Eligibility Function Documents:

Document Name Generation Information Available
in Spanish?		 Mass Mailed? What Triggers
Mass Mailing?		 Work Item Information
IL444-3455
Child Care Application*		 Generated when scanned or faxed to CCMS, fields automatically populate. Yes No N/A After you validate the application on the Validate Documents page,
an Application Work Item is created by CCMS.
IL444-3455E
Child Care Redetermination**		 Generated by CCMS on the First Friday of every month and can also be generated by a user on demand using the Generate Documents page.  Yes Yes This form is created monthly on the First Friday of the month for every active case whose eligibility is ending not later than the end of next month.  To generate this form, you must be
in the context of
a case. A Redetermination Work Item is created when a Redetermination form is generated.
IL444-3455G
Request for a Child Care Provider
Change		 Generated on demand by user, using the Generate Documents page. Yes Yes User generates and submits the form using the Generate Documents page. To generate this form, you  must be in the context of a case. If not in the context of a Change of Information Work Item, manually create this Work Item and generate the form.
IL444-3527
Change of Information **		 Generated on demand by user, using the Generate Documents page. Yes Yes User generates and submits the form using the Genaerate Documents page. A new COI Work Item is created when a COI form is generated.
IL444-4480
Request for Additional Information**		 Generated on demand by user, using the Generate Documents page. Yes Yes User generates and submits the form using the Genaerate Documents page. To generate this form, you must be in the context of an Application, Rede, COI, or Provider Work Item AND a Case.
IL444-3514
(N-1-11) Wage Verification**		 Generated on demand by user, using the Generate Documents page. Yes No N/A To generate this form, you must be in the context of a n Application, Rede, or COI Work Item AND a Case.
IL444-4339
Request for Provider Address Change		 On demand by user, using the Generate Documents page. Yes No N/A To generate this form, you must be in the context of a provider. If you are not in the context of an Add/Update Provider Information Work Item, manually create this Work Item and generate the form.
IL444-3455A
(R-6-03) Approval of Request for Child Care Payments		 Generated on demand by user, using the Generate Documents page. Yes Yes User generates abd submits the form using the Generate Documents page. To generate this form, you must be in the context of an Application Rede, or COI Work Item AND a case.
IL444-4178
(R-01-02) Notice of Cancellation of Child Care Payments		 Generated by CCMS on First Friday of every month and can also be generated by a user on demand using the Generate Documents page. Yes Yes This form is created monthly on the First Friday of the month for every active case whose eligibility is ending not later than the end of next month. To generate this form, you must be in the context of Redetermination or COI Work Item AND a case.
IL444-4179
(N-9-98) Denial of Request for Child Care Payments		 Generated by a user on demand using the Generate Documents page. Yes Yes User generates and submits the form using the Generate Documents page To generate this form, you must be in the context of an Application Work Item AND a Case.
IL444-4587
(N-01-01) Notice of Cancellation of Child Care Payments for Child Age 13		 Generated by CCMS on First Friday of every month. Yes Yes This form is created monthly on the First Friday of the month for every active case whose eligibility is ending not later than the end of next month. To generate this form, you must be in the context of a Redetermination or COI Work Item AND a case.
IL444-4590
(N-7-01) Notice of Provider Cancellation from Child Care Case (Provider Closeout)		 Generated by a user on demand using the Generate Documents page. Yes Yes User generates and submits the form using the Generate Documents page. To generate form, must be in the context of Redetermination or Add/Update Provider Information Work Item AND case and provider must be authorized.
3492
Licensed Home Certification/License Exempt Home Certification*		 Generated by CCMS  every month and can also be generated by a user on demand using the Generate Documents page. Yes Yes This form is created monthly by MIS batch process. To generate form, must be in the context of a provider. If you are not in the context of an Add/Update Provider Information Work Item, manually create a this Work Item and generate the form.
3492A
Center Certification*		 This document is generated by CCMS  every month and can also be generated by a user on demand using the Generate Documents page. No Yes This form is created monthly by MIS batch process. To generate this form, you must be in the context of a provider. If you are not in the context of an Add/Update Provider Information Work Item, manually create a this Work Item and generate the form.
3492C
SAMER (Site Administered Monthly Enrollment Report)**		 Generated monthly by CCMS during the third weekend of the month (6th business day prior to last day of month) No Yes This form is created monthly by MIS batch process. To generate this form, you must be in the context of Application, Redetermination, COI or Add/Update Provider Information Work Item AND a case.
3426
Email Agreement**		 Generated by a user on demand using the Generate Documents page. Yes No N/A You do not need to be in the context of a Work Item.
IL444-3461
License Exempt Child Care Center Self-Certification**		 Generated by a user on demand using the Documents Links page. No No N/A N/A
IL444-2790 
Self-Employment Record		 Generated by a user on demand using the Documents Links page. Yes No N/A N/A
IL444-3455F
Request for Reimbursement		 Generated by a user on demand using the Documents Links page. Yes No N/A N/A
IL444-4469 - Child Care Rate Certification Form Generated by a user on demand using the Documents Links page. Yes No N/A N/A
W-9 Form Generated by a user on demand using the Documents Links page. Yes No N/A N/A
IL444-3455B
(R-8-07) Important Parent Co-Payment Information		 Generated by a user on demand using the Documents Links page. Yes No N/A N/A
IL444-4341
(R-4-07) Child Care Payment Rates for Child Care Centers		 Generated by a user on demand using the Documents Links page. Yes No N/A N/A
IL444-4343
(R-4-07) Child Care Payment Rates for Home Based Child Care Providers		 Generated by a user on demand using the Documents Links page. Yes No N/A N/A
IL444-4773
Child Care Telephone Billing Agreement		 Generated by a user on demand using the Documents Links page. Yes No N/A N/A
IL444-4003 Responsibility and Service Plan (RASP)* This document is NOT generated in CCMS. No No N/A N/A
IL444-2151 IDHS Referral* This document is NOT generated in CCMS. No No N/A N/A
IL444-2151A Contracted Provider's Referral* This document is NOT generated in CCMS. No No N/A N/A
IL444-2151D
Teen Parent Progress Report Form		 This document is NOT generated in CCMS. No No N/A N/A
IL444-3085 IDHS Contract Report Notification of Employment This document is not generated in CCMS. No No N/A N/A
Child Care Telephone Billing System Notice Generated by a user on demand using the Documents Links page. No No N/A N/A
Child Care Telephone Billing Practice Licensed Home Generated by a user on demand using the Documents Links page. No No N/A N/A
Child Care Telephone Billing Practice Licensed-Exempt Home This document is generated by a user on demand using the Documents Links page. No No N/A N/A
IL444-0800 Illinois Debit MasterCard Payment Option Form This document is generated by a user on demand using the Documents Links page. Yes No N/A N/A

Customer Service Function Documents:

Document Name Generation Information Available in Spanish? Mass Mailed? What Triggers Mass Mailing? Work Item Information
IL444-4194
(R-1-11) Authorization for Background Check**		 Generated by a user on demand using the Generate Documents page. Yes Yes User generates and submits the form using the Generates Documents page. To generate this form, you must be in the context of an Add/Update Provider Information Work Item.
IL444-3522
Relative Background Check Letter		 Generated by a user on demand using the Generate Documents page. Yes Yes User generates and submits the form using the Generate Documents page. Provider type of care 765 & 767 receive this cover letter. To generate this form, you must be in the context of an Add/Update Provider Information Work Item.
IL444-3523
Non-Relative Background Check Letter		 Generated by a user on demand using the Generate Documents page. Yes Yes User generates and submits the form using the Generate Documents page. Provider type of care 764 & 766 receive this cover letter. To generate this form, you must be in the context of an Add/Update Provider Information Work Item.
IL444-1900
(R-10-09) Overpayment Referral Form		 Generated by a user on demand using the Generate Documents page. No No N/A To generate this form, you must be in the context of an Overpayment Work Item AND a case.
IL444-3518
Overpayment Calculation Worksheet		 Generated by a user on demand using the Generate Documents page. Yes No N/A To generate this form, you must be in the context of an Overpayment Work Item AND a case.
IL444-3520
(N-1-11) Child Care Overpayment Letter		 Generated by a user on demand using the Generate Documents page. Yes No N/A To generate this form, you must be in the context of an Overpayment Work Item AND a case.
IL444-3519
(N-1-11) Provider Overpayment Letter		 Generated by a user on demand using the Generate Documents page. Yes No N/A To generate this form, you must be in the context of an Overpayment Work Item AND a case.
IL444-3515
(N-1-11) Parent Overpayment Letter		 Generated by a user on demand using the Generate Documents page. Yes No N/A
IL444-3517
(N-1-11) Provider Overpayment Change Letter		 Generated by a user on demand using the Generate Documents page. Yes No N/A
IL444-3516
(N-1-11) Rescind of Overpayment		 Generated by a user on demand using the Generate Documents page. Yes No N/A
IL444-4338
Attendance Exemption Request
(12-2000)		 Generated by a user on demand using the Generate Links page. No No N/A
IL444-0102
Statement of Facts		 Generated by a user on demand using the Generate Documents page. Yes No N/A
IL444-0065
Request to Withdraw Appeal*		 Generated by a user on demand using the Generate Links page. No No N/A
IL444-0103
Notice of Appeal*		 Not generated in CCMS Yes No N/A
IL444-1456
Implementation of Appeal Decision		 Generated by a user on demand using the Generate Links page. No No N/A
IL444-4289
Request to Establish Accounts		 Generated by a user on demand using the Generate Links page. Yes No N/A
IL444-3521
License Exempt Center Background Check Letter		 Generated by a user on demand using the Generate Links page. No No N/A

PIQA - Program Integrity and Quality Assurance

Document Name Generation Information Available in Spanish? Mass Mailed? What Triggers Mass Mailing? Work Item Information
Outcome Letter (Report) Generated by a user on demand using the Generate Documents page. No No N/A To generate this form, you must be in the context of a Field Review Work Item.
Confirmation Letter (Report) Generated by a user on demand using the Generate Documents page. No No N/A To generate this form, you must be in the context of a Field Review Work Item.
Child Care Fraud Referral form Generated by a user on demand using the Generate Documents page. No No N/A To generate this form, you must be in the context of a Field Review Work Item.