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DSS-6189 State Maternity Fund Residential Care Provider Agreement - info dhhs state nc-2026
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- Click ‘Get Form’ to open the DSS-6189 agreement in the editor.
- Begin by filling in the names of the Service Agency and Care Provider in the designated fields at the top of the form.
- Enter the location of the Care Provider and specify the reimbursement amount per day for room and board services.
- Indicate the date when the Client will move into the Care Provider’s facility, ensuring accuracy for reimbursement tracking.
- Complete sections detailing accommodations, meals, and utilities that will be provided to the Client during their stay.
- Fill out emergency contact information as required, including names and phone numbers for immediate notification.
- Review all entered information for accuracy before signing. Ensure both parties sign and date at the bottom of the form.
Start using our platform today to easily complete your DSS-6189 agreement online for free!
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DSS-6189: State Maternity Fund Residential Care Provider Agreement. Open Preview. File Type: pdf. File Size: 133 KB. Categories: Social Services.Read more