8000, Required Forms and Reports

Revision 22-2; Effective April 1, 2022

Required Form or Report (1): Monthly Voucher Packet

  • Description: Includes Form B-13X, Form 4116, Authorization for Expenditures, and Form Data Management
  • Submission Date: By the last business day of the month following the month in which expenses were incurred or services provided. Final voucher due within 45 days after end of the contract term.
  • Accepted Method of Submission: Email
  • Submit Copy to: PSPS_Finance@hhs.texas.gov
  • Original Signature Required: No
  • Number of Copies: One
  • Instructions: Enter Cost Reimbursement monthly expenses per budget category, program income collection and data collection. 
  • Note: The Monthly Voucher Packet templates are sent to contracted providers by their contract manager. Vouchers must be submitted each month even if there are no expenditures. Vouchers must still be submitted each month for actual expenditures of the program even if the contract limit has been reached. 

Required Form or Report (2): Financial Status Report (FSR) Form 269A

  • Description: Quarterly report encompassing all expenditures and program income for the defining three months with amount received from HHSC.
  • Submission Date: Reports are due as follows: Quarter 1: September through November; Quarter 2: December through February; Quarter 3: March through May; Quarter 4: June through August. Submit 30 days after the end of each quarter. The final quarterly FSR is due 45 days after the end of the contract term. The final quarter report includes all final charges and expenses associated with the program contract. Mark it as "Final."
  • Accepted Method of Submission: Email
  • Submit Copy to:  PSPS_Finance@hhs.texas.gov
  • Original Signature Required: Yes
  • Number of Copies: One
  • Instructions: Form 269A must have an original signature (scanned email or fax accepted).  

Required Form or Report (3): Fee-for-Service Report       

  • Description: Fee-for-Service (File furnished voucher through Texas Medicaid & Healthcare Partnership (TMHP) TexMedConnect/Compass 21)
  • Submission Date: Claims Filing Deadline: Within 95 days from date of service or date of third-party insurance EOB form. Within 45 days after the end of the contract term.
  • Accepted Method of Submission: TMHP/Compass 21
  • Submit Copy to: Not applicable
  • Original Signature Required: No
  • Number of Copies: Not applicable
  • Instructions: Claims must continue to be submitted to TMHP TexMedConnect/Compass 21 even if the contract limit has been reached.
  • Note: Appeals must be submitted within 120 days of rejection during the contract term. All appeals must be submitted and finalized within 45 days after the end of the contract term.

Required Form or Report (4): Financial Reconciliation Report (FRR) 

  • Submission Date: No later than 60 days after the end of the contract term.
  • Accepted Method of Submission: Email, scan or fax
  • Submit Copy to:  PSPS_Finance@hhs.texas.gov
  • Original Signature Required: Yes
  • Number of Copies: Not applicable
  • Instructions: The FRR form requires a signature (scan or fax accepted). The FRR is necessary only if the contractor has only a fee-for-service component without a cost reimbursement component. 

Required Form or Report (5): Form 1080, Health and Developmental Services (HDS) Promotion and Outreach Annual Plan

  • Description: This plan should outline the contractor’s goals to inform the public of the purpose of the program and available services, enhance community understanding of its objectives, disseminate basic family planning and women’s health care knowledge, enlist community support and recruit potential clients for FPP. 
  • Submission Date: The report is due within 45 days of the start of the contract period.
  • Accepted Method of Submission: Email
  • Submit Copy to: famplan@hhs.texas.gov 
  • Original Signature Required: No
  • Number of copies: Not applicable
  • Instructions: Submit completed plan annually by due date outlined.

Required Form or Report (6): Form 1060, Health and Developmental Services (HDS) Promotion and Outreach Quarterly Report

  • Description: This report should include summary of the efficacy of program promotion and client outreach activities outlined in Form 1080, Health and Developmental Services (HDS) Promotion and Outreach Annual Plan.
  • Submission Date: The report is due within 15 days of the close of each quarter.
  • Accepted Method of Submission: Email
  • Submit Copy to: famplan@hhs.texas.gov 
  • Original Signature Required: No
  • Number of Copies: Not Applicable
  • Instructions: Submit completed reports quarterly by the due date outlined.