The New Hampshire 2620 form is a Child Care Provider Enrollment Form required by the Department of Health and Human Services for individuals and organizations providing child care services. This form ensures that providers are officially enrolled to receive payments and comply with state regulations. Completing this form is essential for anyone looking to offer child care services in New Hampshire.
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The New Hampshire 2620 form is a crucial document for individuals and organizations providing child care services in the state. This form, officially titled the Child Care Provider Enrollment Form, is used to enroll providers with the Department of Health and Human Services (DHHS) to ensure they can receive payments for their services. It requires essential information such as the provider's name, contact details, and the type of child care services offered. Providers must indicate whether they report income under their Social Security Number or an Employer Identification Number. Accurate completion of the form is vital, as it establishes a Resource Identification Number, which is necessary for billing purposes. Additionally, any changes to the provider's information must be reported using this form, ensuring that DHHS has the most current data on file. Understanding the requirements and processes associated with the New Hampshire 2620 form is essential for compliance and to facilitate timely payments for child care services rendered.
State of New Hampshire
Department of Health and Human Services
Form 2620
Division for Children, Youth and Families
March 2009
CHILD CARE PROVIDER ENROLLMENT FORM
TRANSACT ION CODE
Effective Date of the Transaction
(Check 1 Only)
Add
Change
Close
month
day
year
Resource Identification Number (Use on change/close transactions only)
SECTION 1
PROVIDER’S NAME (Please Note: If you are reporting income with a Social Security Number, use your name here not the name of your business. If you are reporting income with an Employer Identification Number, use your business name here.)
DOING BUSINESS AS (DBA) Complete this line only if you report income to the IRS under your Social Security Number and you choose to have a business name. You must also complete your name above.
-
Employer Identification Number (EIN)
OR
Social Security Number (SSN)
SECTION 2
Provider’s Physical Address (Street)
Provider’s Physical Address (Town/City)
State
Zip Code
Provider’s Billing or Mailing Address (Street)
Provider’s Billing or Mailing Address (Town/City)
Provider’s E-mail Address
PLEASE NOTE: All provider payments are directed to the Provider’s Billing or Mailing Address. If you are a provider who forwards payments to a separate billing address or corporate headquarters, you must indicate the correct billing address above to avoid delays in payment.
Provider Contact Person (First and Last name)
Contact Person’s Telephone Number
Provider’s Telephone Number (if different than contact person)
SECTION 3
Services Provided: Check the box for the service you provide:
31 Child Care-Licensed Center
32 Child Care-License-Exempt Family/Friend/Neighbor
33 Child Care – Licensed Family or Family Group Child Care Home 34 Child Care – License-Exempt Center
PD 09 - 05
INSTRUCTIONS FOR COMPLETION OF PROVIDER ENROLLMENT FORM
All providers of child care services who wish to receive payment from the Department of Health and Human Services (DHHS) must be enrolled and are subject to all Department rules, regulations, policies, and procedures. This is done with completion of a child care enrollment packet. No payments will be made to any provider until the enrollment process has been completed. DHHS does not withhold tax money for individuals receiving payments for services. Payment of taxes is the responsibility of the individual.
Enrollment and Billing: At time of enrollment, all providers will be assigned a Resource Identification (ID) Number. A Provider Enrollment Notice will be sent informing you that the enrollment process has been completed.
Please retain this notice! The Provider Notice will give you the information required to be entered on all billing invoices that you submit to DHHS. To be reimbursed for child care services, you must bill on
DHHS billing invoice Form 2500.
Reporting Changes: Providers are required to report all changes to DHHS such as changes of address, incorporation, or provider name. Changes must be reported to DHHS by submitting them on a new FORM 2620 and ALTERNATE W-9 FORM to the address listed below. These two forms must be mailed together.
Form Completion
Transaction Code Add- Check when you request a new enrollment. Transaction Code Change- Check when you report a change, or are re-enrolling. Transaction Code Close- Check when you request to close your enrollment.
Resource ID Number- Enter your Resource ID number when you report a change or request an enrollment closing. Enter your number from left to right leaving unused spaces blank at the end.
Effective Date- Enter month, day, year. This date will be your first date of enrollment, date child care services will be provided by you, the effective date of your change, or your enrollment end date.
Provider Name - This line must be completed whether you report income under your SSN# or EIN# Enter your own name here if you report income to the IRS under your Social Security Number.
Enter the name of your business here only if you report income to the IRS with an Employer Identification Number.
Doing Business As- Complete this line only if you report income to the IRS under your Social Security Number. If you have a business name, enter it. You must also indicate your first name, middle initial and last name on the line provided above.
Employer ID Number or Social Security Number- Enter the number you use to report income to the IRS (Enter only one number- either the SSN# or the EIN#).
Provider Address- Enter your physical and billing or mailing address. (See note on the front of this form)
Contact Person- Enter the name, telephone number and email address of the person to contact for questions.
Services Provided- Check the box for the child care service you provide.
Return this form, along with a completed ALTERNATE W-9 FORM, to the:
Data Management Unit
Box 2000
Concord, NH 03302-2000
What is the New Hampshire 2620 form?
The New Hampshire 2620 form is a Child Care Provider Enrollment Form issued by the Department of Health and Human Services (DHHS). It is required for all providers of child care services who wish to receive payment from DHHS. The form collects essential information such as the provider's name, business name (if applicable), physical and mailing addresses, contact information, and the type of child care services offered. Completing this form is a prerequisite for enrollment in the DHHS payment system.
Who needs to complete the New Hampshire 2620 form?
Any individual or organization that provides child care services in New Hampshire and seeks payment from the DHHS must complete the New Hampshire 2620 form. This includes licensed centers, license-exempt providers, and family child care homes. The enrollment process ensures that providers are recognized by the DHHS and can receive reimbursement for their services.
What information is required on the New Hampshire 2620 form?
The form requires various pieces of information, including the provider's name, business name (if applicable), Social Security Number or Employer Identification Number, physical and mailing addresses, contact person details, and the type of services provided. Accurate completion of this information is crucial to avoid delays in processing and payments.
How does one report changes after submitting the New Hampshire 2620 form?
If there are changes to the provider's information, such as a change of address or business name, these must be reported to the DHHS using a new New Hampshire 2620 form and an Alternate W-9 Form. Both forms should be mailed together to the DHHS Data Management Unit at the specified address. It is important to report changes promptly to ensure that payments are not disrupted.
What happens after submitting the New Hampshire 2620 form?
After the submission of the New Hampshire 2620 form, the DHHS will assign a Resource Identification Number to the provider. A Provider Enrollment Notice will then be sent to the provider, confirming that the enrollment process has been completed. This notice is important as it contains information necessary for billing DHHS for services rendered.
What is the purpose of the Resource Identification Number?
The Resource Identification Number serves as a unique identifier for each child care provider enrolled with the DHHS. It is essential for billing purposes and must be included on all invoices submitted for reimbursement. This number helps the DHHS track payments and ensure that they are processed accurately and efficiently.
Misconceptions about the New Hampshire 2620 form can lead to confusion among child care providers. Understanding the facts surrounding this form is essential for successful enrollment and compliance. Here are four common misconceptions:
This is incorrect. The form is required for all child care providers, including licensed centers, license-exempt family/friend/neighbors, and licensed family or family group child care homes. Each type of provider must complete the form to receive payments from the Department of Health and Human Services.
Submitting the form does not guarantee immediate payment. Providers must first complete the enrollment process, which includes receiving a Resource Identification Number. Only after this process is finalized will providers be eligible to bill for services rendered.
This is not true. Providers must report all changes, such as address updates or name changes, in writing by submitting a new New Hampshire 2620 form along with an Alternate W-9 form. Verbal communication is insufficient for official record-keeping.
This is a misunderstanding. The billing address is crucial for processing payments. Providers must ensure that they provide an accurate billing or mailing address to avoid delays in receiving payments.
The New Hampshire 2620 form serves as a vital document for child care providers seeking enrollment with the Department of Health and Human Services. Several other forms share similar purposes or functionalities, which can aid in understanding the context and requirements of the 2620 form. Below are seven documents that exhibit similarities:
Nhdes W 06 0030 - The form requires personal information including the applicant’s name, address, and contact details.
The important Hold Harmless Agreement form is vital for safeguarding parties involved in events that could pose risks. It clearly indicates the responsibilities each party assumes, preventing liability claims after specific activities.
Can I Get W2 From Irs - Providers should report any overpayments received to DHHS promptly.