Learn about the Medicaid 1115 Transformation Waiver Renewal.
For information about COVID-19, call 2-1-1 and select Option 6.
Find a COVID-19 testing site | COVID-19 vaccine | More COVID-19 information
Some forms cannot be viewed in a web browser and must be opened in Adobe Reader on your desktop system. Click here for instructions on accessing your form.
Form 4116 is used to organize data for entry into the Texas Health and Human Services Commission (HHSC) accounting system for HHSC authorized expenditures. Form 4116 can also be used as part of an internal control process and to document required approvals.
Using Form 4116 for the wrong type of expenditures will lead to processing delays or the request being rejected.
All purchases and the resulting accounting transactions must be made in accordance with the Texas and United States Constitutions, applicable statutes and regulations, HHSC and the Texas comptroller’s office policies and rules.
The officer and employees are responsible for:
- being knowledgeable about Texas law and rules concerning expenditures;
- being knowledgeable about HHSC internal policies, standards and requirements concerning expenditures;
- ensuring the agency’s expenditures comply with those laws and rules;
- determining the agency’s legal authority for making each payment that would result from the purchase document before the document is submitted to the comptroller;
- ensuring that for each purchase document, the agency maintains necessary documentation for proving that each payment resulting from the document is legal, proper and fiscally responsible; and
- ensuring that each purchase document complies with the processing requirements of CAPPS and USAS.
Note: Staff who make purchases outside applicable statutes, rules, policies and procedures may be held personally responsible for those purchases.
When to Prepare
HHSC employees should use Form 4116 for the following:
- Authorized emergency payments;
- Authorized unencumbered payments (made per Health and Human Services (HHS) procurement policy);
- Verification and/or certification of services;
- Employee reimbursements, such as manager-approved employee non-travel reimbursements (made per HHS procurement policy);
- Notary application fees;
- HHS Printing services. For information, visit https://www.dshs.texas.gov/hhsprinting/;
- Grants; and
- Other expenditures as authorized by the “Approval and Signature Authority for HHS Agency Contracts Circular C-046”.
1. Agency No.: Enter the 3-digit agency number where the funds are coming from. This field identifies the agency whose accounting data will be impacted by the transaction.
2. Agency Name: Enter the state agency.
3. Current Document No. (AP Use Only): Enter the agency assigned eight-character document number.
4. Texas Identification Number and Mail Code (Required): Enter the vendor’s 11-digit TIN number followed by the three-digit mail code.
5. PDT (Optional): Enter the payment distribution type (up to two characters) or leave blank to be looked up in TINS for each detail transaction.
6. Document Amount (Required): The document amount is the sum of all transactions entered for a document number without regard to the accounting impact.
7. Payee Name/Address (Required): Enter the vendor/payee name and remit to address.
8. Purchase Order ID and Contract No. (Required if Exists): Enter CAPPS HHSC purchase order number and contract number.
9. SFX: Enter the three-digit suffix number of the transaction.
- Ref Doc (Optional): Enter the eight-character reference document number or leave blank.
- T-Code (AP Use Only): Enter the three-digit transaction code used to determine the accounting impact of each transaction.
- CONF (Optional): If applicable, choose the one-character confidential indicator.
- Y = Yes
- S = Some
- N = No
- RTI (Required for interagency payments (ITV) ONLY): Enter the six-character Recurring Transaction Index for interagency transactions only.
- Orig. Payment Date (Restricted): Enter the six-digit date that the warrant was originally issued (MMDDYY). This field is used only for payments to replace a lost or stolen warrant.
- AY/REF (Required): Enter the two-digit appropriation year (YY) that provides the funding for the expenditure.
- Class/PCA (Optional – Inferred): If applicable, enter the five-digit Class/PCA or leave blank, to be inferred by CAPPS SpeedChart number.
- Prj./Grant (Optional – Inferred): If applicable, enter the valid project/grant number or leave blank, to be inferred by CAPPS SpeedChart number.
- Account/COBJ (Required): Enter the six-digit CAPPS expenditure account number (COBJ - comptroller object code).
- Amount (Required): Enter the amount (up to 11 digits and two decimal places).
- R – Reverse (Restricted): To reverse the accounting impact of a transaction, use a reverse (RVS) code of "R."
- APPN (Not Required): Leave blank, to be inferred by CAPPS SpeedChart number.
- Fund (Not Required): Leave blank, to be inferred by CAPPS SpeedChart number.
- Invoice Received Date (Required): Enter the six-digit invoice received date (MMDDYY) – the date that HHSC first received an invoice in strict accordance with any instructions on the purchase order (PO) and/or contract relating to the payment.
- Invoice Date (Optional): If applicable, enter the six-digit invoice date (MMDDYY).
- Payment Due Date (Not Required): Leave blank for the system-generated default.
- Requested Payment Date (Optional): If applicable, enter the six-digit requested date (MMDDYY) to establish a payment distribution date different than the payment due date. Entry must comply with all policies and procedures.
- Interest Control (Optional – Restricted): If applicable, enter the one-character interest control (IC) or leave blank for the system-generated default.
- Reason (Optional – Restricted): If applicable, enter the two-character Interest Control Reason Code (ICRC) or leave blank for the system-generated default.
- Invoice No. (Required): Enter the invoice number (up to 30 alphanumeric characters). The invoice number is required for expenditure transactions based on the T-Code. It must be unique for each payment.
- Description (Required): Enter a brief description for the goods or service.
- Ser/Del Date: Enter the six-digit service or delivery date (MMDDYY). This date identifies the date of which goods or services are received or rendered.
- Dept ID (Optional – Inferred): If applicable, enter the department ID or leave blank, to be inferred by CAPPS SpeedChart number.
- Program (Optional – Inferred): If applicable, enter the program number or leave blank, to be inferred by CAPPS SpeedChart number.
- SpeedChart (Required): Must enter the SpeedChart number. Important: Required entry for all payments.
10. SER/DEL Date (Required): Enter the six-digit service or delivery date (MMDDYY). This date identifies the date for which goods or services are received or rendered.
11. Description of Goods or Services (Required): Enter a description of the goods or services in sufficient detail.
- 11a. SCOR Contract No. – If applicable, enter HHSC contract number.
- 11b. SCOR Service Dates – If applicable, enter HHSC contract SCOR service dates.
12. Quantity: Enter amount or number of an item/good.
13. Unit Price: Enter cost per item/good.
14. Amount: This is the product of the quantity multiplied by unit price.
15. Payee Verification/Certification Signature, Phone No. with Area Code and Payee Contact Name: If applicable, this section must be completed by the payee as a verification/certification that services were rendered according to all terms and conditions.
16. HHSC Contact Signature, Phone No. with Area Code and HHSC Contact Name (Optional): If applicable, this section must be completed by HHSC staff that completed form.
17. Approved Signature, Mail Code, Phone No. with Area Code and Date (Required): Completing these fields is required. Only authorized HHSC staff given approval authority to enter into or approve a payment may sign. Staff may not authorize payments if they are the requestor, payee or beneficiary of the services. Two signatures of approval are required. Both lines must be filled out each by a different approver.