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REQUEST FOR A CHILD CARE PROVIDER CHANGE

State of Illinois Department of Human Services REQUEST FOR A CHILD care PROVIDER CHANGE CHILD care Case Number: _____ Date: _____ Client: _____ can reach you during the day: Hm: _____ Wk: _____ List a phone number where we _____ _____ ONLY Complete & Return WHEN you CHANGE or ADD Another PROVIDER DO NOT fill this out if you have already sent in a form for your new PROVIDER . If you CHANGE providers or add another PROVIDER , you and your new PROVIDER must complete and SIGN the attached pages. Be sure to also complete this cover page. Return this cover page with the attached pages to the address listed below. We MUST have this information before we can make payments to your new PROVIDER . You and your PROVIDER will be notified within 30 days after we receive the completed information. After your new PROVIDER is approved, we will send the new PROVIDER a billing form, called a CHILD care Certificate. If you are CHANGING providers, complete this box.

CHILD CARE RESOURCE SERVICE Child Care Assistance Program 314 Bevier Hall, 905 S. Goodwin IL444-3455G (N-7-00) If your new child care provider is not willing to complete the attached pages, call _____ for a parent counselor at the …

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STATE OF ILLINOIS DEPARTMENT OF HU MAN SERVICES

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