Form 2031-G, Designation of Authorized Individual(s) – Governmental Entity

Instructions

Updated: 3/2020

Purpose

Form 2031-G provides a mechanism for a governmental 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-G 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-G in accordance with record retention requirements in the Health and Human Services System Contract Management Handbook.

Instructions for Governmental Entity Completing Form 2031-G

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

• The official name of the governmental 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 governmental entity.
• The “Doing Business As” name of the governmental 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 governmental 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 governmental entity.
• The type of governmental entity.
• The signature of the authorizing official of the governmental entity.
• Typed or printed name and title, if any, of the authorizing official of the governmental entity.

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