8000, Required Forms and Reports

Revision 23-4; Effective Nov. 17, 2023

Required Form or Report (1): Monthly Voucher Packet

  • Description: Includes Form B-13X, Form 4116, 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 grant 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 grantees 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 grant 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 amounts 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 grant term. The final quarterly report includes all final charges and expenses associated with the program grant. 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 grant 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 grant award amount has been reached.
  • Note: Appeals must be submitted within 120 days of denial during the grant term. All appeals must be submitted and finalized within 45 days after the end of the grant term.

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

  • Submission Date: No later than 60 days after the end of the grant 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 grantee has only a fee-for-service component without a cost reimbursement component. 

Required Form or Report (5):  Promotion and Outreach Annual Plan

  • Description: This plan should outline the grantee’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. Grantees may use the Promotion and Outreach Plan Template (Form 1060) in the Forms section as an optional framework for this internal plan.
  • Submission Date: The report will be completed by the contractor within 45 days of the start of the grant period and kept on file for monitoring purposes.
  • Accepted Method of Submission: Not applicable, plans should be kept on file and do not need to be submitted to HHSC. 
  • Submit Copy to: Grantees will keep the Promotion and Outreach Annual Plan on file for monitoring purposes. The plan will not be submitted to HHSC.
  • Original Signature Required: No
  • Number of copies: Not applicable
  • Instructions: Submit completed plan annually by due date outlined.

Required Form or Report (6): Promotion and Outreach Bi-Annual Survey

  • Description: This survey will be sent via email to designated FPP signature authorities bi-annually. Grantees are required to complete the survey within 30 days. 
  • Submission Date: The report is due within 30 days of receipt.
  • Accepted Method of Submission: Email
  • Original Signature Required: No
  • Number of Copies: Not Applicable
  • Instructions: Submit completed surveys bi-annually by the due date outlined.