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.
- Copy of National Provider Identifier (NPI) notification letter (Not required for non-healthcare services)
- Copy of required license(s), if applicable
- Verification of the Employer Identification Number (EIN). Send a copy of the Internal Revenue Service (IRS) award letter OR payment coupon.
- Form 2031, Governing Authority Resolution, Business Organization OR
Form 2031-G, Governing Authority Resolution, Governmental Entity - Form 3681, Community Services Contract Application
- Form 3691, Service Area Designation [Not required for Adult Foster Care (AFC), Assisted Living/Residential Care (AL/RC) and Out of Home Respite (OHR)]
- Form 3691-A, Service Area Designation [For Home and Community-based Services (HCS), Texas Home Living (TxHmL), Consumer Directed Services (CDS) and Transition Assistance Services (TAS) in lieu of Form 3691
- Form 5871, Disclosure of Ownership and Control Interest Statement OR
Form 5871-S, Disclosure of Ownership and Control Interest Statement — Short Form
Section II: Program-specific forms for community services programs indicated in parenthesis
- Form 2357, DFPS Records Check: Adult Foster Care (AFC)
- Form 3647, Assisted Living Disclosure Statement: Assisted Living (AL)
- Form 3681-A, Community Services Contract Application, Addendum A: Adult Foster Care (AFC), Assisted Living/Residential Care (AL/RC) and Out of Home Respite (OHR)
- Form 3681-B, Community Services Contract Application, Addendum B: Adult Foster Care (AFC)
- Form 3681-C, Community Services Contract Application, Addendum C: Emergency Response Services (ERS)
- Form 4223, Client Services HUB Subcontracting Plan, Application Status Determination: [Relocation Services, Special Services to People with Disabilities (SSPD), and Consumer Managed Personal Attendant Services (CMPAS)]
- Form 4224, HUB Subcontracting Plan, Subcontractor Status Determination for Vendor and Grant Contracts: [Relocation Services, Special Services to People with Disabilities (SSPD), and Consumer Managed Personal Attendant Services (CMPAS)]
- Form 5872, Certification of Pre-Application Orientation: Home and Community Support Services (CBA/CWP/ICM), and Primary Home Care/Family Care/Community Attendant Services (PHC/FC/CAS), Day Activity and Health Services (DAHS), and Community Living Assistance and Support Services (CLASS)
- Click here to view and download the HCSS (CBA/CWP/ICM) and PHC/FC/CAS Pre-Application Orientation Guide (PDF)
- Click here to view and download the DAHS Pre-Application Orientation Guide (PDF)
- Click here to view and download the CLASS Pre-Application Orientation Guide (PDF)
- Click here to view and download the MDCP Pre-Application Guide (PDF)
- Copy of Child and Adult Care Food Program (CACFP) agreement must be obtained within four months of receiving a contract (DAHS).
- Copy of Centers for Medicare and Medicaid Services (CMS) Medicare certification letter (Hospice)
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)