Effective Date: 
4/2017

Documents

Instructions

Updated: 4/2017

Purpose

Form 3681 is completed by individuals and organizations to apply for a Health and Human Services Commission (HHSC) contract to provide Community Services and, if applicable, to enroll in Texas Medicaid.

Note: In addition to completing Form 3681, applicants who want to provide the following services must also complete the forms indicated.

  • Adult Foster Care or Residential Care: Form 3681-A, Community Services Contract Application — Addendum A
  • Adult Foster Care: Form 3681-B, Community Services Contract Application — Addendum B, Adult Foster Care Provider Questionnaire
  • Emergency Response Services: Form 3681-C, Community Services Contract Application — Addendum C, Emergency Response Services

Instructions for HHSC Staff

When to Prepare

Obtain a completed and signed Form 3681 for:

  • a new contract; or
  • an update to information on the form.

Form Retention

Retain Form 3681 and attachments in accordance with the records retention requirements in the Health and Human Services System Contract Management Handbook.

Applicant's Instructions for Completing Form 3681

If you are a new applicant and you want to contract with HHSC to provide any Medicaid services, you must enroll in Texas Medicaid. To enroll in Texas Medicaid, a new applicant, except an applicant that wants to obtain a Home and Community Services (HCS) or Texas Home Living (TxHmL) contract, must complete and submit Attachment A, Application Fee Payment Form, and the fee payment with the application packet. A new HCS or TxHmL applicant should not submit Attachment A and the fee payment until after being notified by HHSC that the entity’s program manager has passed the competency exam for the required provider training.

Note: Applicants that intend to bill acute care services through Texas Medicaid & Healthcare Partnership (TMHP) must enroll in Texas Medicaid through TMHP. Information about enrolling in Texas Medicaid may be accessed at https://hhs.texas.gov/doing-business-hhs.

A new applicant is not required to enroll in Texas Medicaid to obtain the following contract types:

  • Community Care for Aged and Disabled – Adult Foster Care (CCAD-AFC)
  • Community Care for Aged and Disabled – Emergency Response Services (CCAD-ERS)
  • Community Care for Aged and Disabled – Home- Delivered Meals (CCAD-HDM)

Carefully read the following instructions. Errors and omissions will cause delays in processing Form 3681.

Section 1. Type of Applicant — Check the applicable box. If you are a current provider, indicate the purpose of your application.

Section 2. Applicant's Legal Entity Information

Name of Legal Entity — Enter the full legal name of the entity, exactly as it was chartered, filed, registered or otherwise legally declared. If the applicant is an individual, enter the full legal name of the individual.

Doing Business As (d/b/a) — If applicable, enter the d/b/a(s) relevant to this contract.

Taxpayer Identification No. — Enter the 9-digit employer identification number (EIN) assigned to the legal entity by the Internal Revenue Service (IRS). If the legal entity is a sole proprietorship or individual who does not have an EIN, enter the owner's or individual's Social Security number (SSN).

Provider Identifier No. (NPI or API) — Enter the 10-digit National Provider Identifier (NPI) number issued to the legal entity by the National Plan and Provider Enumeration System (NPPES) or the Atypical Provider Identifier (API) number assigned by HHSC, whichever is applicable.

Name of Owner — If the legal entity is a sole proprietorship, enter the owner's legal name. If the legal entity is not a sole proprietorship, leave blank.

Legal Entity Business Mailing Address — Self-explanatory.

Legal Entity Physical Address — Self-explanatory. If same as business mailing address, enter "same."

Location Where Service Delivery Records are Maintained — Indicate where service delivery records are maintained if location is different from entity's physical address. If address is the same, enter "same." For HCS and TxHmL service providers, this address must be in the contract waiver area(s) selected on Form 3691-A, Service Area Designation — HCS, TxHmL, CDS and TAS.

Authorized Representative — Enter the name of the person who is included on Form 2031, Governing Authority Resolution — Business Organization, or Form 2031-G, Governing Authority Resolution — Governmental Entity, whichever is applicable. Enter the name of the owner if sole proprietorship.

Email Address — Self-explanatory.

Area Code and Telephone No. — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Section 3. Applicant's Type of Legal Entity — Check the applicable box to indicate the legal entity's type of business organization.

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

Sole Proprietor

  • Copy of Social Security Card
  • Copy of Driver License
  • Certificate of Assumed Business Name as filed with the County

Corporation (for-profit and nonprofit)

  • Certificate of Formation as filed with Secretary of State
  • Certificate of Registration (if not formed in Texas, authority to transact business in Texas) as filed with Secretary of State
  • Articles of Incorporation
  • Bylaws, if applicable
  • Certificate of Assumed Business Name as filed with Secretary of State
  • Proof of IRS Tax ID Number (IRS Form CP-575 or LTR 147c)
  • Certificates of Amendments to original filing, if applicable

General Partnership

  • General Partnership Agreement
  • Certificate of Assumed Business Name as filed with Secretary of State
  • Copy of Social Security Card for each partner
  • Copy of Driver License for each partner
  • Proof of IRS Tax ID Number (IRS Form CP-575 or LTR 147c)
  • Any amendments to original General Partnership Agreement, if applicable.

Limited Partnership

  • Certificate of Formation as filed with Secretary of State
  • Limited Partnership Agreement
  • Certificate of Registration (if not formed in Texas, authority to transact business in Texas) as filed with Secretary of State
  • Certificate of Assumed Business Name as filed with Secretary of State
  • Certificates of Amendments to original filing, if applicable
  • Proof of IRS Tax ID Number (IRS Form CP-575 or LTR 147c)
  • Copy of Social Security Card for each partner
  • Copy of Driver License for each partner

Limited Liability Partnership

  • Applicable general or limited partnership documents (see above)
  • Evidence of filing Registration of a Limited Liability Partnership as filed with Secretary of State

Limited Liability Company

  • Certificate of Formation as filed with Secretary of State
  • Certificate of Registration (if not formed in Texas, authority to transact business in Texas) as filed with Secretary of State
  • Articles of Organization
  • Certificate of Assumed Business Name as filed with Secretary of State
  • Certificates of Amendments to original filing, if applicable
  • Proof of IRS Tax ID Number (IRS Form CP-575 or LTR 147c)

Section 4. Adverse Actions and Convictions — Answer questions A through F as applicable to the legal entity identified in Section 2. If any question is answered Yes, attach a full explanation of the circumstances.

For questions A and B, "convicted" means that

  1. A judgment of conviction has been entered against an individual or entity by a federal, state or local court, regardless of whether:
    1. there is a post-trial motion or an appeal pending, or
    2. the judgment of conviction or other record relating to the criminal conduct has been expunged or otherwise removed;
  2. A federal, state or local court has made a finding of guilt against an individual or entity; or
  3. A federal, state or local court has accepted a plea of guilty or nolo contendere by an individual or entity.

Convicted does not include successful completion of a period of deferred adjudication community supervision and receipt of a dismissal and discharge in accordance with Texas Code of Criminal Procedure, Article 42.12, Section 5(c).

For question C, "sanction" is defined as recoupment, payment hold, imposition of penalties or damages, contract cancelation, exclusion, debarment, suspension, revocation or any other synonymous action.

Section 5. Legal Entity Ownership — Answer questions A through E as applicable to the legal entity identified in Section 2. If any question is answered Yes, provide the information requested.

Section 6. Internal Review Requirement — Answer the question Yes or No.

Note: A new applicant must screen its employees and contractors to determine if they have been excluded from Medicare, Medicaid or any federal or state health care program. The HHS Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE) website is available at https://oig.hhs.gov/exclusions/. The HHSC OIG LEIE website is available at https://oig.hhsc.state.tx.us/oigportal/EXCLUSIONS.aspx.

Section 7. Type of Contract You Want to Obtain

Type of Contract — Click on Community Services Contract Types for a list of contract types. Enter the contract type abbreviation listed in the first column to indicate the type of contract you want to obtain. Make separate entries for each contract type you want to obtain.

Section 8. For Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Only

8a. Program and Billing Person

Program and Billing Contact Person — Provide the information requested for the individual who should be contacted about waiver program service issues and billing questions and issues.

8b. Program Manager

Provide the information requested for the individual who is responsible for managing and overseeing the direct provision of services to individuals enrolled in the HHSC waiver program(s) and ensuring the legal entity's compliance with certification provisions and the terms and conditions of the provider agreement.

Note: This individual must attend the next scheduled provider applicant training and complete the certification exam. There are no exceptions to this requirement. Also, no substitutions for this individual during the application process are allowed. A written resume and three signed and verifiable professional references for this person must be submitted with this form.

Section 9. Licensure Information

9.a. For all Texas Health and Human Services (HHS) License Holders

Complete 9.a. if you want to obtain a contract type that requires an HHS license. Otherwise, leave blank. Copy this page and include as an attachment if additional entries are required.

License No. — Enter the license number indicated on the license.

License Type — Enter "Facility" or "HCSSA," whichever is applicable.

Facility Category — Check the category of the license, if applicable.

HCSSA Category — Check the category or categories of the license, if applicable.

HCSSA Branch Office — Enter the location of any branch office that will provide services for the contract type(s) you want to obtain (HCSSA only).

9.b. For Day Activity and Health Services and Assisted Living License Holders Only

Legal Right to Occupy — Check Yes or No to indicate if the legal entity identified in Section 2 has a legal right to occupy the property in which the facility is located. Note: The applicant/legal entity may be required to submit proof of its legal right to occupy the property.

Real Property Ownership Information — Provide the information requested for the individual or business entity that owns the real property in which the facility is located.

Section 10. Applicant/Legal Entity Certification

The owner or an authorized representative of the legal entity must certify the information provided on the form, as well as all attachments, is true and complete. 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 HHS.

Documents

Community Service Contract Types

 

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