CCAPLegalNonLicProvider

Legal Nonlicensed Provider Registration Packet
Child Care Assistance Program (CCAP)
Payments will not be made to you until the registration process has been completed and you have been approved as a registered provider

Required Registration Forms
Legal Nonlicensed Provider Registration and Acknowledgment (DHS-5192)
Complete the entire form and return. It is IMPORTANT to submit ALL of the information indicated on the form.

W-9 Tax Form
Complete form and return.

Authorization for Release of Background Study (DHS-5193)
This form is required to be completed for providers providing care for families in Pope County. The provider and anyone in the household age 13 and older must complete this form.

Authorization for Release of Information from the Bureau of Criminal Apprehension
This form is required to be completed for providers providing care for families in Pope County. The provider and anyone in the household age 13 and older must complete this form.

Pope County Human Services - Consent and Release for Law Enforcement & Agency Records
This form is required to be completed for providers providing care for families in Pope County. The provider and anyone in the household age 13 and older must complete this form.

Wadena County Social Services Department - Consent and Request for Law Enforcement & Agency Records
This form is required to be completed for providers providing care for families in Wadena County. The provider and anyone in the household age 13 and older must complete this form

Individual Background Study Form - Becker County Legal Non-Licensed Child Care Program
This form is required to be completed for providers providing care for families in Becker County. The provider and anyone in the household age 13 and older must complete this form.

Optional Forms
Direct Deposit for the Minnesota Child Care Assistance Program (DHS-3552)
This enables you to receive payments directly to your bank account.

MECĀ² PRO Information and Registration form
This is information about the electronic billing system that is used for CCAP programs. Complete form if wanting to use this easy access system to receive payments.

CCAP Financial Tracking Form (DHS-5318)
Use this form to record payments for child care fees or expenses when third-party payments are received by your child care program from sources other than Child Care Assistance.

CCAP Quality Differential Rate Request Form (DHS-4795)
Complete if you are requesting to be paid at the accreditation rate. You must meet certain credentials to qualify.

Special Needs Rate Variance Request Form (DHS-4194)
Complete if you are requesting to be paid at a higher rate to care for a child with special needs. Both you and the parent must complete the form.

Informational
The documents below are provided for your reference. They do not need to be returned

Training Requirements for Legal Nonlicensed Family Providers- Questions and Answers (DHS-6419)

Health and Safety Resource List (DHS-5192A)

Child Care Provider Responsibilities and Rights  (DHS-4079)

Notice of Privacy Practices for Child Care Providers (DHS-3985)

Standard Maximum Rates
Lists the current child care rates that are reimbursable through the Child Care Assistance Program.

CCAP Provider Guide (DHS-5260)
 

Return all materials to:
Lakes and Prairies
Child Care Assistance Program
715 11th St N suite 402
Moorhead, MN 56560
Fax: 218-299-7547

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