Form 3681-C, Community Services Contract Application Addendum C - Emergency Response Services

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Documents

Effective Date: 7/2017

Instructions

Updated: 7/2017

PURPOSE

Form 3681-C is an addendum to Form 3681, Community Services Contract Application, and is used by contractors to obtain a contract to provide Emergency Response Services (ERS).

When to Prepare

Form 3681-C is prepared for:

  • a new contract,
  • an update of information, and
  • a contract amendment.

Form Retention

Retain Form 3681-C in accordance with the retention requirements in the HHS System Contract Management Handbook.

Detailed Instructions

Note: Attach a copy of each document requested, if applicable.

Section 1. Legal Entity Information

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

2. Doing Business as Name (DBA) — If applicable, enter the legal entity's DBA.

3. Taxpayer Identification No. — Enter the nine-digit federal employer identification number (FEIN) for business entities and the Social Security number for individuals.

4. National Provider Identifier — Enter the National Provider Identifier (NPI) number assigned the legal entity by the Centers for Medicare and Medicaid Services (CMS) and/or by the state survey agency, if applicable.

5. Base Station Physical Address — Self-explanatory.

6. HHSC Region — Enter the number of the HHSC region for which you wish to provide services.

Section 2. Service Area and Rate

1. County/Counties to be Served — List the county or counties you propose to serve under the contract or check the box indicating you will serve all counties in the region indicated in Section 1. A list of counties by service region can be viewed by clicking on List of Counties by Service Region at the end of these instructions.

2. Proposed Rate — Enter the rate the legal entity offers to provide ERS under contract with HHSC. The rate offered cannot exceed the maximum rate for the HHSC ERS program.

3. Private-Pay Rates — Check the appropriate box to indicate whether the legal entity provides ERS to private-pay customers. If Yes, enter in the table the rates charged private-pay customers for the same services (equipment and monitoring) the legal entity proposes to provide HHSC under contract. If a monthly equipment fee is charged, indicate whether the fee is for use of the equipment or for purchase of the equipment. If the monthly equipment fee is for purchase of the equipment, indicate how many monthly payments are required to pay for the equipment in full.

Section 3. Subcontractor Information

Complete the subcontractor information table if the legal entity uses any subcontractors to install or monitor ERS equipment. If a person who installs or monitors ERS equipment is not a bona fide employee of an agency, the person is a subcontractor.

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

Services — Indicate whether the subcontractor installs and/or monitors ERS equipment.

Note: Attach copies of agreements or contracts for all subcontractors.

Section 4. Assurances

Provide the name, title or position, telephone number and mailing address of the person responsible for managing the legal entity's contract with HHSC.

Section 5. Legal Entity Certification

The owner or authorized representative of the legal entity identified in Section 1 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 a current Form 2031 or Form 2031-G, whichever is applicable to the legal entity.

List of Counties by Service Region