Community Services Provider Forms & Documents

You must complete and submit all required forms and documents listed in Section I. Complete and submit program-specific forms and documents listed in Section II.

Failure to submit the applicable forms and documents listed in Sections I and II will delay the contract enrollment process. Carefully read the instructions before completing a form as errors and omissions will delay the contract enrollment process.

Section I: Forms and documents for all community services providers

All of the following forms and documents must be submitted regardless of the type of community service provided, unless indicated otherwise.

Section II: Program-specific forms for community services programs indicated in parenthesis

The following items must be made available for review for the community services programs indicated.

  • Adult Foster Care (AFC)
    • Most recent health inspection
    • Most recent fire inspection
    • Tuberculosis tests performed within the last six months
    • Proof of current pet vaccinations
    • Copies of criminal history background checks
    • Copy of unexpired driver's license or Texas ID
    • Copy of floor plan that includes evacuation plan
  • Assisted Living/Residential Care (AL/RC)
    • Copy of floor plan
  • Programs of All-Inclusive Care for the Elderly (PACE)
    • Copy of Child and Adult Care Food Program (CACFP) agreement (DAHS) must be obtained within four months of receiving a contract.
    • Copy of PACE program agreement signed by Centers for Medicare and Medicaid Services (CMS)