Provider Demographic Information

Please confirm/correct the information below, fill in blanks when applicable, and return this form to DHS with your financial report submission.

Note: Information on this form is used by the DHS Office of Contract Administration to fulfill various administrative responsibilities. Changes to information on this form will not affect information used by other offices within DHS.

• FEIN
• Provider
• Doing Business As (DBA)
• Fiscal Year End
• Not For Profit
• For Profit
• Taxpayer Type*
• Contact
• Title
• Address Line 1
• Address Line 2
• City, State, Zip
• Phone Ext.
• FAX
• EMail Primary
• EMail Secondary

Valid Taxpayer Types are:

• Corporation, other than hospital
• Hospital
• Individual
• Partnership
• Regional Office of Education
• School District
• Sole Proprietorship
• Unit of County Government
• Unit of Municipal Government
• Unit of State Government
• University, College or Junior College