MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION SUBSIDIZED GUARDIANSHIP AGREEMENT ATTACHMENT
CONTRACT NUMBER
CHILD’S NAME	DOB	DCN	LEGAL GUARDIAN(S) NAME	DVN
THIS DOCUMENT REPLACES ANY PRIOR ATTACHMENT TO A SUBSIDY AGREEMENT BETWEEN THE CHILDREN’S DIVISION AND THE LEGAL GUARDIAN(S) CONCERNING THE CHILD NAMED ABOVE
SERVICE DESCRIPTION	CODE	CONTRACTED SERV. (Y/N)	MEDICAID PROVIDED SERVICE (Y/N)	RECURRING YEARLY=Y MONTHLY=M ONE TIME ONLY=O	MAXIMUM AMOUNT	APPROVAL TIME
BASIC SUBSIDY – MEDICAID (MEDICAL PROVIDER WILL UTILIZE THEIR PRIVATE INSURANCE PRIOR TO ACCESSING MEDICAID)	BEGIN
END
MAINTENANCE	$	BEGIN
END
DAYCARE	$	BEGIN
END
$	BEGIN
END
$	BEGIN
END
$	BEGIN
END
$	BEGIN
END
$	BEGIN
END
EXPLANATION
REVIEWED BY	SIGNATURES
CHILDREN’S SERVICE WORKER	DATE	LEGAL GUARDIAN	DATE
CIRCUIT MANAGER OR PLACING AGENCY/DESIGNATED REPRESENTATIVE	DATE	LEGAL GUARDIAN	DATE
REGIONAL DIRECTOR OR DESIGNATED REPRESENTATIVE	DATE	ADDRESS
CENTRAL OFFICE UNIT MANAGER (WHEN REQUIRED)	DATE
ADDRESS	APPROVAL BY
DIRECTOR, CHILDREN’S DIVISION	DATE