Follow the steps to complete the form successfully.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the provider or contractor name in the designated field. This is a mandatory field and should represent the name of the organization or individual requesting the background check.
3. Enter the Provider ID assigned by the Department of Economic Security (DES). Ensure that this number is accurate to avoid processing delays.
4. Specify the type of center or home by selecting between the licensed center number or certified group home number. Complete the respective field accordingly.
5. Provide the tracking number if applicable and the CCA contract number, marking the correct box to indicate the type of request.
6. Complete the phone number, including the area code, and the email address where results will be sent. Double-check the email for accuracy.
7. Fill in the city and ZIP code of the provider’s location to aid in the identification of the facility.
8. Identify the person authorized to submit the request, ensuring their name is printed or typed clearly in the respective field.
9. Sign the request to confirm its accuracy and authenticity. This signature must match the authorized individual identified earlier.
10. Set the date of the request by entering the current date in the provided field.
11. Review all filled fields to ensure accuracy and completeness. Once verified, you can save your changes, download the completed form, print it, or share it as required.

Complete your documents online today to streamline your application process.