Effective Date: 
1/2013

Documents

Instructions

Updated: 1/2013

Purpose

Form 3600 is used as an application for participation in Title XIX Medicaid for the following facility types: intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID), nursing facility or rural hospital.

Procedure

Complete Form 3600 when applying for:

  • new Medicaid facility
  • adding Medicaid beds to licensed-only facility or Medicare-certified facility
  • ownership change
  • re-certification after termination
  • re-opening a previously Medicaid-certified facility

Complete Form 3600 to report changes in:

  • facility, mailing, business addresses
  • telephone, fax numbers, email addresses
  • facility name (with supporting documentation)
  • legal entity name (with supporting documentation)
  • management company
  • real estate

Return completed/notarized form to:

Texas Health and Human Services Commission
Regulatory Services E-330
P.O. Box 149030
Austin TX 78714

For overnight delivery only:

Texas Health and Human Services Commission
Regulatory Services E-330
701 W 51st St.
Austin TX 78751

Call 512-438-3556 and ask for either a nursing facility or an ICF/IID contract specialist if you have any questions regarding the Medicaid enrollment process.

Form Retention

Retain Form 3600 in accordance with the contract and provider agreement requirements.

Detailed Instructions

Section 1. Facility Information – Check the applicable box for program type. Enter the facility name (doing business as [DBA], if applicable), facility ID number, NPI number¹, physical address, facility telephone and fax numbers, number of approved Medicaid beds, administrator's email address, and facility mailing address² and business address.

¹ All HHSC health care providers, whether they are individuals or organizations, must obtain an NPI for use to identify themselves in HIPAA standard transactions. Effective September 2006, HHSC requires providers completing a contract application packet to include their NPI and provide a copy of the NPI approval letter. The application will not be considered complete unless the NPI is provided.

² The business address is reserved for warrants in the event that no direct deposit is in place.

Section 2. Type of Application – Check the applicable box for application type. If Management Company Change is included, enter name of management company, tax ID and address.

Section 3. Applicant – Legal Entity Information

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

Federal Tax Identification No./SSN – Enter the nine-digit federal employer identification number (FEIN) assigned the legal entity by the IRS or the Social Security number if a sole proprietorship.

Fiscal Year End  – Enter the fiscal year end date of the applicant.

Business Mailing Address – Self-explanatory.

Contact Person – Enter the name, title or position and telephone number of the person who can answer questions about the information furnished on the form. Also provide this person's email address and fax number.

Applicant Type of Entity – Check the applicable box to indicate the legal entity's type of business organization.

Attach the following certificates and documents applicable to the entity's type of business organization.

For Sole Proprietor

  • Copy of Social Security card
  • Copy of driver license or ID card

For General Partnership

  • General Partnership Agreement
  • Assumed Name Certificate (County)

For Corporation

  • Certificate of Account Status (State Comptroller)
  • Certificate of Formation (Secretary of State)
  • Certificate of Registration (if foreign entity) (Secretary of State)
  • Articles of Incorporation
  • By-Laws (if applicable)
  • Assumed Name Certificate (Secretary of State)

For Limited Liability Company

  • Certificate of Account Status (State Comptroller)
  • Certificate of Formation (Secretary of State)
  • Certificate of Registration (if foreign entity) (Secretary of State)
  • Articles of Organization
  • Regulations of Organization
  • Assumed Name Certificate (Secretary of State)
  • Any Certificates of Amendments

For Limited Partnership

  • Certificate of Formation (Secretary of State)
  • Limited Partnership Agreement or
  • Regulations of Limited Partnership
  • Certificate of Registration (if foreign entity) (Secretary of State)
  • Assumed Name Certificate (Secretary of State)
  • Any Certificates of Amendments

For City, County, State or Federal Government Authority or Hospital District

  • Documents that authorized the formation and established the existence of the Government Authority or Hospital District/Authority (obtained by city, council, county commissioners court or state/federal legislative branch)
  • By-Laws or Regulations of Government Authority or Hospital District/Authority

Section 4. Preparer – Provide information for the contractor or firm that is preparing the application.

Section 5. Lease, Sublease, Mortgage and Lien Data – Provide data concerning leases, subleases, mortgages, liens, deeds of trust, or notes or obligations secured by any property of the facility. Identify all individuals or firms who are owners (in whole or in part) of any type of obligation secured (in whole or in part) by any property or assets of the facility. If a facility is leased or subleased, the lessor must be listed.

Section 6. Additional Applicant/Legal Entity Information – Answer questions A through H as applicable to the legal entity reflected in Section 2. If any question is answered Yes, attach a full explanation of the details and circumstances.

Section 7. Medicaid Contract Application Affidavit – The owner or authorized representative of the legal entity identified in Section 2 must certify the information provided on the form and all attachments are true and correct. If an authorized representative provides this certification, that person 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. This form must be notarized and include the notary's seal or stamp.

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