APPLICATION FOR CERTIFICATION AND ENROLLMENT OF SECURE TRANSPORTATION SERVICE PROVIDERS

Date:

for dcyf office use only
Date of Compliance Verification:	NH Bridges Provider Number:
NH Medicaid Number:	National Provider Identification Number (NPI):

part a:	identifying information
Name of Law Enforcement Agency:	Federal Taxpayer ID Number (TIN):
Office Address:
Mailing Address:	Telephone:
City/Town:	State:	Zip Code:	Fax Number:
Name of Billing Contact:	Telephone # of Billing Contact:
Agency’s Website Address:	Email Address:

part B:	authorization/statement of understanding
I have reviewed the Administrative Rules He-C 6343 and will adhere to the rules as a certified provider. I authorize the NH Division for Children, Youth and Families (DCYF) to conduct a certification for payment review to determine the agency’s compliance with Administrative Rules He-C 6343. I further understand that DCYF has the right to verify information contained in this application. The information contained in this application is correct to the best of my knowledge. I acknowledge that the provision of false information in the application is a basis for denial of the application.
Signature of Applicant	Date
Printed Name of Applicant

Below mentioned items MUST be submitted with the application in order for Certification to occur:

A completed, signed, and dated State of New Hampshire Alternate W – 9 (October 2016)

Return Completed Application to:	NH Department of Health and Human Services	or	Email: DCYFCertificationunit@dhhs.nh.gov
Division for Children, Youth and Families
Community Based Services Certification
129 Pleasant St
Concord, NH 03301-3857