APPLICATION FOR CONTINUED CERTIFICATION AND ENROLLMENT OF COMMUNICATION ACCESS SERVICE PROVIDERS

Provider Type
Deaf or Hearing Loss	Foreign Language

Part A:	Identifying Information
Name of Applicant:	Federal Taxpayer Id Number (TIN)
Or
Last 4 of Social Security Number (SSN)	XXX-XX-
Physical Address:
Billing Address (if different)	Telephone:
City/Town:	State:	Zip Code:	Fax Number:
Languages in which you are proficient:
Email Address:

If applying as an agency, please complete this section:

Name of Agency:	Federal Taxpayer Id Number (TIN):
Physical Address
Billing Address:	Telephone:
City/Town:	State:	Zip Code:	Fax Number:
Name of Billing Contact Person:	Telephone # of Billing Contact:
Agency Website Address

Part B: Please complete the following: (Individual Applicants complete first line. For Agency Applicants, please provide information for each agency staff providing services.)

Please list the full name and job titles, type of license and license expiration date for each employee who provides communication access services. During service certification period, agency must send any new staff information to the DCYF Certification Specialist. For each staff listed here, please ensure they complete, sign and date their own Part D.
Last Name	First Name	MI	Maiden Name	Job Title	License	License Expiration

Part C: Please complete the following:

Does the individual or agency applicant have Liability Insurance?	Yes	No

Has the individual or agency applicant ever had any Liability Insurance policy revoked?	Yes	No

If “yes” please state the reason why it was revoked.

Part D:	Information
Name of Individual Applicant or Agency Applicant Staff:
Each Individual Applicant and Agency Applicant staff who will provide communication access services must answer the following questions. If any questions are answered “yes”, please provide additional information including dates, details and results on a separate sheet and submit it with the application. Copy this page for each Agency Applicant staff providing communication access services.
Have you ever:	YES	NO
1.	Been subject to disciplinary action by a licensing body or professional society?
2.	Been found civilly liable for professional misconduct?
3.	Been found to have committed an ethical violation by a state or national professional association or any state’s regulatory board?
4.	Had membership in a professional society or association revoked?
5.	Had any other type of disciplinary action or professional sanction by a licensing body or professional society?
6.	Had any judgments or settlements made against you in a professional liability case or are there any pending law suits?
7.	Had a conviction of any felony or any convictions of any crimes against a person?
8.	Been involved with a report or founded case of abuse or neglect in which you were the person to have allegedly caused the abuse or neglect?

I declare that all the information contained above is true, correct and complete to the best of my knowledge and belief. I acknowledge that the provision of false information in the application is a basis for denial of the application.

___________________________________________	_______________________________

Signature of Individual Applicant or Agency Applicant Staff	Date

Part E: Statement of Affirmation

I have reviewed Administrative Rule He-C 6341 and will adhere to the rules as an enrolled provider. I understand that DCYF has the right to verify information contained in this application.

I understand and agree that any individual or agency providing services with whom I employ or subcontract will have a current and valid license for the service being provided.

Below mentioned items MUST be submitted with the application in order for enrollment to occur.

License to Practice or Operate
State of New Hampshire Alternate W-9

__________________________________________________________	_____________________

Signature of Individual Applicant or Agency Applicant Executive Director	Date

_____________________________________________________________

Printed Name of Individual Applicant or Agency Applicant Executive Director

Return Completed Application to:	NH Department of Health and Human Services or
Division for Children, Youth and Families
Provider Relations
129 Pleasant St
Concord, NH 03301-3857

For DCYF Office use only
Enrollment Valid:	From:	To:	NH Bridges Provider Number:
Approved for Initial Enrollment
Approved for Enrollment Renewal:	Provider relations:
Signature