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Nebraska cc-28 Child Care Medical Appointment Form

Nebraska's Office of Economic Assistance can pay for child care while a parent attends medical services, and this one-page verification documents that need. The physician confirms the patient is receiving care, names the type of care, and estimates appointment length, frequency and how many months the appointments will continue. Introduced in May 2026, it sits alongside the CC-3E Incapacity Statement.

Who completes it

The examining physician (the signature line specifies Medical Doctor) completes everything below the patient's name and Social Security number, including the parent or guardian name if applicable, and signs with printed name and address.

Submitting and payment

How to submit it
Return the form to DHHS Economic Assistance; the worker places it in the individual's case file and no additional copies are required.

Good to know

  • It covers time the parent receives physician, mental health or drug and alcohol treatment services, takes a child to medical care and cannot bring the other children, or visits a hospitalized child or spouse.
  • Examples of care types listed on the form include medical, mental health, substance abuse, physical therapy, dialysis and chemotherapy.
  • If the appointment length is unknown, the form asks for an estimate in hours rather than a blank.
  • Worker instructions say the form is completed only when an individual requests child care to obtain medical services; incapacity requests use CC-3E instead.

Get the official form

Download the current version from the source each time; forms change without notice.

Child Care Medical Appointment Verification

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

When is Nebraska form cc-28 used?

When a parent asks for child care services so they can obtain medical services. It applies to time spent in physician, mental health or drug and alcohol treatment, taking a child to medical care when the other children cannot come along, or visiting a child or spouse in the hospital.

What does the physician fill in on cc-28?

Whether the patient is receiving care, the type of care (for example medical, mental health, substance abuse, physical therapy, dialysis or chemotherapy), the average appointment length in hours, how often appointments occur, and how many months they will continue, followed by signature, date, printed name and address.

How is cc-28 different from CC-3E?

CC-3E documents a parent's incapacity that eliminates their ability to care for their children. cc-28 documents scheduled appointments, so child care covers only the hours the parent is at medical, mental health or treatment visits.