The New Hampshire 2631 form is a Child Care Provider Agreement for those participating in the Child Care and Development Fund (CCDF) Scholarship Program. This agreement outlines the responsibilities and requirements for license-exempt child care providers to ensure compliance with state regulations. Understanding and completing this form is crucial for providers to receive payments for their services, so take a moment to fill it out by clicking the button below.
The New Hampshire Form 2631 serves as a critical agreement for license-exempt child care providers participating in the Child Care and Development Fund (CCDF) Scholarship Program. This form outlines the responsibilities and requirements that providers must adhere to in order to receive funding for child care services. Key aspects of the agreement include the necessity for providers to be at least 16 years old, the stipulation that they cannot reside with the children for whom they provide care, and the limitation on the number of children that can be cared for at one time. Providers must also agree to bill for services only after they have been rendered and maintain accurate attendance records. Compliance with all relevant laws and policies is essential, as failure to do so may result in termination from the program and potential further action by the Department of Health and Human Services (DHHS). The form also emphasizes the importance of confidentiality and the need for providers to report any overpayments or discrepancies. Additionally, it clarifies the relationship between providers and parents regarding charges for services, ensuring that all billing practices are transparent and accurate. The completion and submission of Form 2631 is a prerequisite for participation in the CCDF program, making it a vital document for those in the child care sector in New Hampshire.
STATE OF NEW HAMPSHIRE
Form 2631
Department of Health and Human Services
March 2009
Division for Children, Youth and Families
Child Care And Development Fund Scholarship
CHILD CARE PROVIDER AGREEMENT
License-exempt Child Care
Name of Provider
Program Name
of
Street Address
City, State and Zip
agrees to participate in the New Hampshire Child Care Development Fund (CCDF) Scholarship Program and comply with all the requirements set forth in this agreement.
I understand that failure to comply with the terms of this agreement is grounds for termination of participation in the New Hampshire CCDF Scholarship Program and for possible further action by the Department of Health & Human Services (DHHS).
I agree to comply with all laws, rules, policies, and procedures, including enrollment requirements and billing directions, regarding CCDF.
I agree to bill only for child care services provided in compliance with this agreement.
I agree to bill only for the time the child was in attendance.
I understand that as a child care provider:
1.I must be 16 years of age or older;
2.I may not reside in the same home as the parent and/or child for whom I am providing care;
3.I will not be paid for providing care to my own children; and,
4.I can provide care for up to 3 children, other than my own, at any given time.
I agree to bill DHHS weekly for services provided in the previous week on the Child Care Payment Request Invoice (Form 2500) or on the automated web billing system. I agree that invoices will not be paid unless they are completed correctly and are submitted to DHHS within 90 days after the services were provided.
I agree that by submitting an invoice to DHHS for services provided, I am certifying that the bill is true and accurate.
I understand that the Department will recover any payment made for inaccurate or fraudulent billing.
I agree that I will be the only person to submit invoices to DHHS for children under my care and supervision.
I agree that if I choose to submit invoices through the automated web billing method, DHHS will assign a Personal Identification Number (PIN) to me. I understand that I am responsible for all invoices submitted to DHHS using the PIN and that this PIN is non-transferable.
I agree that I will not sign or submit the child care payment request invoices until after the services have been provided. I further agree that I will not have the parent sign the child care payment request invoices until after the services have been rendered.
PD 09-05
I agree that at all times for children receiving CCDF Scholarship under my care and supervision, I will be present and will directly provide care for those children.
I agree to keep all information concerning children and their families confidential except as otherwise allowed under law.
I agree to keep daily attendance records, which include start and stop times and parent/guardian’s signature, and other records related to billing for a period of seven years. I agree to provide all such records and information related to billing and/or services provided to DHHS or its agents as requested.
I agree to contact DHHS if I believe that I have received an overpayment.
I agree to be responsible for reporting funds received under this agreement as income to DHHS each calendar year as required if I am receiving any other services from DHHS.
I agree that I am responsible for the payment of all required federal and state taxes accrued. DHHS will issue a Form 1099 in January of each year if total reportable payment from all state agencies equal $600 or more.
**Note Form 1099 will not be issued for nonprofit agencies or corporations.
I agree that signing this form does not create an employer-employee relationship.
I agree that the decision to charge or not to charge all or part of the cost share determined by DHHS is between the provider and the parent.
I agree that the decision to charge all or part of the difference between what DHHS reimburses and the actual charge is between the provider and the parent.
I understand that I may be terminated from participation in CCDF for failure to comply with this agreement or DHHS rules related to child care assistance. Additionally, I understand that either party may terminate this agreement without cause following 30 days written notification by registered mail. This agreement may be terminated without advance notice if the provider has not billed in over one year, a child’s health or safety is endangered or if the provider is determined to have fraudulently billed DHHS.
Any provider that has a founded fraudulent claim against them will be disqualified from participating in the CCDF Scholarship program for a minimum period of five years.
This agreement becomes effective upon the date of your signature:
__________________________________________________________________________________
Name of Child Care Provider
___________________________________
_______________________________________
Signature
Date
Return this signed form to the Child Development Bureau
129 Pleasant Street
Concord, New Hampshire 03301
Keep a copy for your records
Form 2631(i)
Instructions for License-Exempt Child Care Provider Agreement
PURPOSE:
All license-exempt child care providers enrolled through the Department of Health and Human Services to receive payments for providing child care through Child Care and Development Fund Scholarships must date and sign the agreement upon enrollment.
INSTRUCTIONS:
Form 2631 must be completed by the child care provider. The completed form must be returned to the Child Development Bureau, Division for Children, Youth and Families.
The Child Development Bureau will return forms that have missing or incomplete information.
The Child Development Bureau will retain a copy of the completed form in the provider file.
FORM COMPLETION:
Enter the full legal name and physical address of the child care provider.
Read the entire document and if you have any questions contact the Child Development Bureau.
Sign and date the form.
Send original and keep a copy for your records.
RETENTION:
Form 2631 is retained permanently in the provider file.
What is the purpose of the New Hampshire 2631 form?
The New Hampshire 2631 form serves as a Child Care Provider Agreement for license-exempt child care providers participating in the Child Care and Development Fund (CCDF) Scholarship Program. By signing this form, providers agree to comply with specific requirements and regulations set forth by the New Hampshire Department of Health and Human Services (DHHS). This agreement ensures that providers understand their responsibilities, including billing practices and maintaining confidentiality regarding the children and families they serve.
What are the eligibility requirements for child care providers under this agreement?
To be eligible to participate in the CCDF Scholarship Program, child care providers must meet several criteria. They must be at least 16 years old and cannot reside in the same home as the child or parent for whom they are providing care. Additionally, providers cannot receive payment for caring for their own children. They are allowed to care for a maximum of three children, excluding their own, at any one time. These requirements ensure that the care provided meets the standards expected by DHHS.
How should providers submit invoices for payment?
Providers are required to submit invoices weekly for the child care services they have provided in the previous week. They can use the Child Care Payment Request Invoice (Form 2500) or opt for the automated web billing system. It is crucial that invoices are completed accurately and submitted to DHHS within 90 days of the services rendered. Inaccurate or fraudulent billing may lead to recovery actions by DHHS, emphasizing the importance of truthful reporting.
What records must providers keep, and for how long?
Providers must maintain daily attendance records that include start and stop times, as well as the signatures of parents or guardians. They are also required to keep other records related to billing. These records must be retained for a period of seven years. This retention period allows DHHS to verify billing and service compliance, and providers must be prepared to provide these records upon request.
What happens if a provider fails to comply with the agreement?
If a provider does not comply with the terms outlined in the New Hampshire 2631 form or the associated DHHS rules, they may be terminated from participation in the CCDF Scholarship Program. Furthermore, either party can terminate the agreement without cause with a 30-day written notice. In cases of severe violations, such as fraudulent billing or endangering a child's health or safety, immediate termination can occur. Providers found guilty of fraud may face disqualification from the program for a minimum of five years.
Here are some common misconceptions about the New Hampshire 2631 form:
Understanding these points can help ensure compliance with the New Hampshire CCDF Scholarship Program and foster better practices in child care services.
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