REQUIRED INFORMATION FOR DDA BILLING WITH THE CITY OF ENUMCLAW
If you have DDA hours to use for respite activities please fill out the form below before you can request billing through the Enumclaw Parks Dept.  After you have signed up I will contact you to let you know you have been approved.

 To request we bill DDA for a class you need to register by the 1st of the month with a grace period until the 5th. After that you may register but not bill DDA.

 Also you must withdraw from the class if you are not going to attend or you will be personally responsible for the registration cost as DDA does not pay for missed classes.

Feel free to contact me with any questions.
Sara 
skirschbaum@ci.enumclaw.wa.us 
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Email *
Name of DDA client *
Client ID Number also called Providerone ID # ends with WA *
Authorization Number if you know it. The number can be found on the upper left hand side of the authorization letters you get from DDA
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Case Managers First and Last Name *
Case Managers email *
Case Managers phone number *
Have you been approved for DDA billing for the current year *
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