PROVIDER FORMS

Report Attendance and System Issues
PRIM ID
Provider License Number*
Submitter's Name*
First Last
Contact Phone*
Contact Email*
How may we assist you?*
- New child was scheduled to begin care, but has not attended
- Child has been absent or not swiped for 5 consecutive days
- Provider Request Drop
- POS or IVR System not working properly
TWIST ID*
Scheduled Start Date*
Start Date of Absences or Non-Swipes*
Drop Date*
Approximate Date and Time the problems began*
Name of child*
First Last
Name of parent*
First Last
Reason Description*
Description of problem*
Existing work Item ticket number

Child Care Assistance Change Notification
PRIM ID
Provider License Number (old one if number is changing)*
Email Address*
Submitter's Name*
First Last
New Phone Number
New Email Address
New Mailing Address
Street Address City ZIP Code
New Physical Address
Street Address City ZIP Code
Operational Change Description: hours, days, age groups served
Hours Days Age Groups Served
New Primary Contact Name
First Last
New Primary person's title
What changes are needed?
- Direct Deposit Change
- Rates Change
Direct Deposit Change Description*
Rates Change Description*
New EIN Number
New License Permit Number
Effective Date of New License Permit Number*
Start Date of Emergency Closer
End Date of Emergency Closer
Reason For Emergency Closer?

PRIM ID
Document Request Form
Choose "Upload Document" to attach a document. After the document is attached, click the "SUBMIT" button. Once your document is submitted, you will get a confirmation email showing that the file was successfully received.
Provider License Number*
Email address*
Submitter's Name*
First Last
Document Type

Provider Document Upload
Choose "Upload Document" to attach a document. After the document is attached, click the "SUBMIT" button. Once your document is submitted, you will get a confirmation email showing that the file was successfully received.
PRIM ID
Provider License Number*
Email address*
Submitter's Name*
First Last
What form does this document apply to?*
File*
Drop files here or

Accepted file types: jpg, png, tiff, pdf, gif.

Report Attendance and System Issues