Form 3681-B is an addendum to Form 3681, Community Services Contract Application, and is completed by individuals who wish to obtain a contract to provide Adult Foster Care Services.
When to Prepare
Individuals complete Form 3681-B when applying to obtain a contract with the Health and Human Services Commission (HHSC) to provide Adult Foster Care.
The HHSC case manager keeps Form 3681-B in a suspense file until the applicant is certified to provide Adult Foster Care. Form 3681-B is then filed in the provider's case folder and retained in accordance with the retention requirements in the HHS System Contract Management Handbook.
Section 1. Identifying Information — The applicant enters information about himself and his spouse and gives directions to his home.
Section 2. Information About Applicant — The applicant enters information about his health status, religious preference, education, employment, income and hobbies.
Section 3. Information About Spouse — The applicant enters information about his spouse's health status, religious preference, education, employment, income and hobbies.
Section 4. Household Information — The applicant enters the names of household members and others living in the household (periodically or temporarily) and enters the following for each:
- Relationship to provider
- School grade or occupation
- Health status
The applicant also enters also the names of individuals employed to work in the applicant's home and the requested information.
Section 5. Health Information — The applicant enters information about his health and that of other household members, medications, emotional problems, medical examinations and physician.
Section 6. Information About the Home — The applicant checks the appropriate boxes and answers questions about transportation for the individual and neighborhood description.
Section 7. Home Environment and Family Attitudes — The applicant checks the appropriate boxes and answers questions about the home environment and family attitudes, including information about the type of individual he would prefer to care for in his home.
Section 8. References — The applicant lists three non-related persons who have known him for more than one year, in addition to two references HHSC staff can contact in case of an emergency.
The applicant checks the appropriate box to indicate if he has provided foster care before or has ever applied to provide foster care.
The applicant enters the name of his referral source and checks the appropriate box to indicate how he heard about the program.
Affidavit — The applicant and spouse (if sharing the same household) attest to the completeness and correctness of the information provided and sign and date the form.