Form 5875, HCS Waiver Program Self-Assessment Certification

Instructions for Opening a Form

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Effective Date: 1/2024


Updated: 5/2017


Before completing Form 5875, the applicant must read and identify how the entity will implement and comply with the HCS Certification Principles outlined in 40 Texas Administrative Code (TAC), Subchapter D, §§9.172 – 9.179.

Detailed Instructions

Legal Entity Name — Enter the legal entity name, which is the name that the Texas Health and Human Services Commission (HHSC) will contract with once all enrollment criteria have been met by the applicant. The legal entity may be one of the following:

  • Sole Proprietorship — A business or financial venture carried on by a single person and which is not a trust or corporation.
  • General Partnership — A contract of two or more competent persons to place their money, effects, labor and skill, or some or all of them, in lawful commerce or business, and to divide the profit and bear the loss in certain proportions.
  • Limited Partnership — An entity in which one or more persons with unlimited liability manage the partnership, while one or more other persons only contribute capital.
  • Corporation — An association of shareholders (or even a single shareholder) created under law and regarded as an artificial person by courts, having a legal entity entirely separate and distinct from the individuals who compose it, with the capacity of continuous existence or succession.
  • Limited Liability Company (LLC) — The limitation placed on the amount an investor of a corporation can lose resulting from a lawsuit against the corporation or other loss suffered by the corporation; the liability for losses that is limited to the amount an investor or shareholder invests in the corporation, unless that amount is determined by a court to have been fraudulently insufficient.

Doing Business As (DBA) — Enter the DBA name. A DBA is an assumed name used by entity. Note: HHSC will not contract with a DBA.

HCS Program Certification Principles — Review, read and understand each of the certification principles as outlined in this section of the form (40 TAC, Subchapter D, §§9.172 – 9.179).

Signature of Authorized Representative — After completing the sections mentioned above, the owner or an authorized representative of the legal entity must sign their full legal entity name and date the form verifying having read the certification principles and agrees to implement and comply with each of the HCS certification principles. If the legal entity is not a sole proprietorship, the authorized representative must be named on a current Form 2031, Governing Authority Resolution — Business Organization, or Form 2031-G, Governing Authority Resolution — Governmental Entity, whichever is applicable to the legal entity, that is on file with HHSC.