DECCD Provider Change of Info Form

Please use this form to update address, phone, email or facility director information.




Please list the name of the person completing this info form (Your Name- First and Last). If you are not the childcare care provider or owner of the business, you must be currently employed by the provider and authorized to submit this form.


Please enter your first and last name as it appears on your account, or the name of the facility as listed on your Child Care License issued by the MS Dept. of Health.






Ex. 601-111-1111


You must have a valid email address that you check daily. All official DECCD communication is sent by email.


Please select the MS county or "Out of State" from the dropdown menu below.



Please list the main informational changes that you are requesting on this form.



ALL DOCUMENTS can be either FAXED, EMAILED or sent via POSTAL MAIL to DECCD or UPLOADED to this form.
Details will be provided at the end of this form.



If YES, Please submit a new license from the MS Dept. of Health as proof of name change.




If YES, Please submit a valid license from the MS Dept. of Health reflecting new residence, or child care facility address.















If YES, your old DECCD profile will be shut down. You must reapply here: http://www.mdhs.ms.gov/early-childhood-care-development/for-providers/application-to-become-an-approved-provider/



If YES, Please submit a copy of the new director's diploma or credentials. Note: All new providers are required to register for and attend the E-Ledger Training Webinar within 30 Days.To register, click: http://www.mdhs.ms.gov/early-childhood-care-development/for-providers/child-care-payment-system-eledger/provider-eledger-training-(webinar)/





ALL DOCUMENTS can be either FAXED, EMAILED, POSTAL MAIL to DECCD or UPLOADED to this form.
Details will be provided at the end of this form.




If YES, Please submit valid MS Driver's License AND a mortgage/utility/medical bill reflecting new residence.















If YES, please submit a Child Abuse Registry Form for All household members available as part of the Non-License Provider Application: http://www.mdhs.ms.gov/media/258124/ECCD-In-Home-Provider-Packet.pdf



Fax Number: 601-359-4422

Email Address: cc.payment@mdhs.ms.gov

Mailing Address:
DECCD
P. O. Box 352
Jackson, MS 39205



If you would like to upload a copy of any document(s) that are required for the specific change you are trying to make, please upload the document(s) here.







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