How to Fill Out the Michigan DHS-4025 Child Care Provider Verification Form

The Michigan DHS-4025 form, officially the MDHHS-4025 Child Development and Care Provider Verification, is what you file to connect a specific child care provider to your Child Development and Care (CDC) benefits case so the state will start paying that provider. You fill in your case details, the provider’s details, each child who needs care, sign the certification, and send it to MDHHS through MI Bridges, by mail, or in person. No payments go out until this form is processed.1Michigan Department of Health and Human Services. MDHHS-4025 Child Development and Care Provider Verification

What You Need Before You Start

Pull these four things together before you open the form. Having them in front of you prevents the most common delays.

Your MDHHS case number. It appears on prior correspondence from the department, such as a benefit approval letter or redetermination notice. If you cannot locate it, your local MDHHS office can look it up for you. You will also need your case name and your specialist’s name.

A chosen provider. If you have not picked one, Michigan maintains a searchable directory of licensed providers at GreatStartToQuality.org, or you can call 877-614-7328 for help. If the provider is license-exempt and not already enrolled with the state, they must complete a separate CDC License Exempt Provider Application (available at Michigan.gov/childcare) before you submit the DHS-4025. One boundary worth knowing: if your license-exempt provider is not related to your child, care must take place in the child’s home, not the provider’s home.1Michigan Department of Health and Human Services. MDHHS-4025 Child Development and Care Provider Verification

The provider’s ID number. This is the state-assigned identification number given to every enrolled provider. Ask the provider directly. Newly enrolled providers receive it after completing enrollment.

The right care-type category. The form asks you to check one of five boxes:

  • Licensed Child Care Center — a state-licensed facility serving larger groups in a commercial setting.
  • Licensed Group Home — a home-based provider licensed to care for seven to twelve unrelated children.
  • Licensed Family Home — a home-based provider licensed to care for one to six unrelated children.
  • Home where child lives — a license-exempt provider who comes to your home.
  • Provider’s home — a license-exempt provider who cares for your child in the provider’s own home.

Pick the correct one the first time. The state applies different rules and payment rates to each category, and the wrong box slows processing.

Filling Out the Form Section by Section

Case Information (Top of Form)

Enter your Case Name, MDHHS Case Number, and Specialist’s name exactly as they appear in MDHHS records.

Child Care Provider Information

In this block, enter the following for the provider you selected:

  • Provider name — the legal business name for a licensed facility, or the individual’s name for a home-based or license-exempt provider.
  • Provider ID number.
  • Full provider address (street, city, state, ZIP).
  • Current provider phone number and email.

Then check the one care-location box that matches the arrangement.1Michigan Department of Health and Human Services. MDHHS-4025 Child Development and Care Provider Verification

Child Information

List every child in your family who will be cared for by this provider. For each child, give:

  • Full legal name as it appears in state records.
  • Date of birth.
  • Date child care began (or will begin) with this provider.
  • Relationship to the provider, including how they are related if they are.

The relationship question matters because the state treats related-provider arrangements differently, including rules about where care can take place and which licensing requirements apply.1Michigan Department of Health and Human Services. MDHHS-4025 Child Development and Care Provider Verification

Using more than one provider? You need a separate DHS-4025 for each. One child at a center and another with a family home provider means two forms.

Certification and Signature

Only the parent or substitute parent signs. There is no line for the provider. Your signature certifies that the information is truthful, that you understand you can be held criminally and financially responsible for false information, and that you have read and agree to all the rules in the CDC Handbook at Michigan.gov/childcare.1Michigan Department of Health and Human Services. MDHHS-4025 Child Development and Care Provider Verification Read the handbook before signing. It spells out your duty to report changes in income, household size, and provider arrangements.

An optional checkbox lets you give your local MDHHS office permission to discuss your CDC case directly with the listed provider. It is voluntary. Checking it can speed up communication if questions come up.

How to Submit the Form

MDHHS accepts the DHS-4025 three ways:

  • Online through the MI Bridges portal at Michigan.gov/mibridges. Log in, go to document uploads, and select the appropriate document type for your case. This is the fastest route.
  • By mail in the postage-paid envelope that came with the form. The envelope is pre-addressed, so you do not need to look up a separate address.
  • In person at your local MDHHS office.

Before you submit by any method, verify three things: the case number is correct, the provider ID is correct, and the form is signed and dated. An unsigned form will not be processed.1Michigan Department of Health and Human Services. MDHHS-4025 Child Development and Care Provider Verification

What Happens After You Submit

MDHHS processes the form and links the provider to your case in the state’s eligibility system. You and the provider both get notices once that happens. If the link is approved, the provider can begin billing the state for care.1Michigan Department of Health and Human Services. MDHHS-4025 Child Development and Care Provider Verification

If something is wrong — a mismatched case number, a provider who is not enrolled, or a missing signature — MDHHS will notify you so you can correct and resubmit. Each round trip costs time.

Here is the piece parents most often miss: your provider cannot bill for care until the link is established. If care has already begun and the form has not been processed, those earlier days may not be covered. Submit the DHS-4025 as early as you can, ideally on or before the date care starts.

Payment rates are set by the state based on the child’s age and the type of provider, not by what the provider charges. The state publishes a CDC Payment Schedule each year, and your family contribution depends on your household income and family size.2Michigan Department of Lifelong Education, Advancement, and Potential. Child Development and Care If the provider charges more than the state pays, you cover the difference. Ask about rates before you commit.

When You Need to File a New DHS-4025

A DHS-4025 links one provider to your case. If any of the following happens during your 12-month CDC certification period, you need to submit a new one:3Michigan Department of Health and Human Services. CDC Program Requirements – BEM 703

  • You switch to a different provider. The old link does not transfer.
  • You add a child to your case who needs care from a provider already on file.
  • A child moves from one care arrangement to another.

The DHS-4025 handles the provider link only. It is not the form for renewing your CDC eligibility — MDHHS runs a separate redetermination before the end of your 12-month certification period, where you verify your need reason and update documentation.