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Page 1 of 2 User Agreement for MEC2 PRO Electronic Billing Purpose: Counties use information provided on this form to grant individual users access to submit bills to the Child Care Assistance Program (CCAP) using MEC² PRO. Complete a separate form for each person. NAME OF AUTHORIZED USER (Enter last name, first name, and middle name) TELEPHONE FAX EMAIL ADDRESS TITLE DO YOU ALREADY SUBMIT BILLS THROUGH MEC2 PRO? Yes No If yes: Current login ID(s): Other agencies: If no, choose a login ID*: *The login ID is used to access MEC2 PRO. It is case sensitive, cannot contain spaces , and must end in “-PRO”. A Login ID cannot be changed once it is created. List each provider this person plans to bill for using MEC2 PRO Provider name License number Provider Tax ID Provider MEC2 ID Acknowledgment: MEC2 PRO User By signing and dating below: I understand I cannot share my MEC2 PRO user access. I have reviewed a copy of the CCAP Child Care Provider Guide (DHS-5260). I have read, and I understand, this information. If I have questions about this information, I will ask a worker to explain it to me. I understand that I can be held criminally and civilly liable if I submit inaccurate CCAP bills to the county or DHS. NAME (print) SIGNATURE OF MEC2 PRO USER DATE *DHS-3813-ENG* DHS-3813-ENG 4-17 Clear Form SIGN ---PAGE BREAK--- Page 2 of 2 DHS-3813-ENG 4-17 Authorized Agent (for licensed providers only) By signing and dating below: I attest and represent that I am an owner, license holder, or controlling individual as defined in M.S. 245A.02, and I am fully authorized to sign this document to bind myself and all other owners, license holders, and controlling individuals to the terms of this agreement. I understand and agree that by signing the document I am representing to the government that all of the information provided, including my signature is true and accurate. Any misrepresentations or failure to provide accurate information can result in possible administrative, civil and criminal sanctions to me, as well as the owners, license holders, controlling individuals and/or the provider/entity. I authorize this MEC2 PRO user to submit bills for my program. I understand and agree to notify the county in writing if the MEC2 PRO user no longer needs to access to MEC2 PRO. Do this when the employee leaves or is no longer in this role. NAME (print) TITLE SIGNATURE OF AUTHORIZED AGENT DATE Agency use area: DATE ENTERED IN MEC2 PRO USER ID TEMPORARY PASSWORD APPROVER’S AGENCY APPROVER’S PHONE NUMBER APPROVER’S EMAIL SIGN