Form 2031, Designation of Authorized Individual(s) - Business Entity

Effective Date
03/2020
Document
Document
2031.pdf (79.76 KB)

 

Instructions

Updated: 3/2020

 

Purpose

Form 2031 provides a mechanism for a business entity to: specify an individual or individuals who may negotiate, execute, implement, maintain, amend, renew or request closure of a contract with the Texas Health and Human Services Commission (HHSC) and notify HHSC when an authorized individual has changed.

 

Instructions for HHSC Staff

When to Prepare

Form 2031 is prepared for a:

  • new contract;
  • change of ownership;
  • Medicaid re-enrollment;
  • Medicaid revalidation; and
  • change of authorized individual(s).

Form Retention

Retain Form 2031 in accordance with record retention requirements in the Health and Human Services System Contract Management Handbook.

 

Instructions for Business Entity Completing Form 2031

Complete the form by filling in the blanks with the following information:

  • The official name of the business entity as registered with the Office of the Texas Secretary of State or, if not required to register, the legal name as established in the organic documents of the business entity.
  • The “Doing Business As” name of the business entity, if applicable.
  • Enter either the Taxpayer Identification Number (EIN or SSN) or the Provider Identifier Number (National Provider Identifier or Atypical Provider Identifier) of the business entity.
  • The full legal name(s), title(s), if any, and email address(es) of the individual(s) authorized to conduct business with HHSC on behalf of the business entity.
  • The type of business entity. If required to register with the Texas Secretary of State, use the business entity type assigned by the Texas Secretary of State.
  • The signature of the authorizing official of the business entity.
  • Typed or printed name and title, if any, of the authorizing official of the business entity.

Note: Submittal of a Form 2031 supersedes, in its entirety, any previously submitted Form 2031.