Form 5872, Certification of Pre-Application Orientation

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Documents

Effective Date: 10/2015

Instructions

Updated: 9/2014

Purpose

Form 5872 is completed by individuals and organizations applying to contract with the Texas Health and Human Services Commission (HHSC) to confirm they read the Pre-Application Orientation Guide required for the following contracts:

  • Community Living Assistance and Support Services (CLASS)
  • Day Activity and Health Services (DAHS)
  • Primary Home Care/Family Care/Community Attendant Services (PHC/FC/CAS)

Procedure

When to Prepare – Instructions for HHSC Staff

Form 5872 is prepared for a new contract.

Form Retention

Retain Form 5872 in accordance with the contract requirements set forth in the Contact Administration Handbook.

Instructions for Completing Form 5872

Carefully read the instructions. Errors and omissions will cause delays in processing Form 5872.

Legal Entity Information

Legal Entity Name — Enter the full, legal name of the entity, exactly as it was chartered, filed, registered or otherwise legally declared.

Certification — Select the program or programs for which the Pre-Application Orientation Guide was reviewed. Select only those programs being applied for at the time of completion.

Legal Entity Signature and Certification

The owner or authorized representative of the legal entity must certify the information provided on the form, as well as all attachments, is true and correct. If an authorized representative provides this certification, that person must be named on current Form 2031, Governing Authority Resolution – Business Organization, or Form 2031-G, Governing Authority Resolution – Governmental Entity, whichever is applicable to the legal entity.