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5.1 PAC OPEN ENROLLMENT APPLICATION, ATTACHMENTS
AND REQUIRED FORMS
INSTRUCTIONS
1. Application must be completed and signed in Section III (Certification) for it to be accepted by DFPS. If it is not signed the Application and Required documents will be sent back to the Applicant to sign it.
2. Applicant will submit their Application in its entirety with all the required documents in File Folders 1 and 2 in Appendix A to REGION12APSCONTRACTS@dfps.texas.gov.
3. If applying in more than one DFPS Region, Applicant will submit one Application. Check all of the counties the Applicant is applying to provide PAC Services.
4. If DFPS has difficulty accessing the Applicant’s documents or they are missing or incomplete, the Applicant will be required to re-submit documents as directed by DFPS.
SECTION I – APPLICANT INFORMATION
| Authorized Signatory |
| Title |
| Authorized Signatory E-mail |
| Authorized Signatory Phone |
Doing Business As Name (DBA) or Parent Organization Indicate if different from Legal Name above:
Attach a copy of Assumed Name Certificate
If an Applicant has a Parent Organization, attach a copy of the agreement between the Applicant and the Parent Organization
Mailing Address - If different from Office Address above Applicant:
Parent Organization: _
Vendor ID Number:
Federal ID Number – If different from Vendor ID Applicant:
Parent Organization:
Name of Person Authorized to Sign Contract
Title
Phone Number:
Email:
Name of Person Responsible for Billing Title Phone Number:
Email:
Type of Applicant – Check appropriate box(es) and attach documentation as indicated
| |_| Governmental Entity | | |
| Do you have taxing authority? | |_|Yes | |_|No |
| |_| Private Corporation |
| |_|For Profit |
| |_|Non-Profit |
| State of Incorporation: |
Charter Number:
Attach a copy of Certificate of Incorporation
|_| Limited Liability Company (LLC)
Attach a copy of the Articles of Formation
| |_| Partnership |
| |_|Limited |
| |_|General |
Attach a list of names, addresses for each partner and provide a copy of the Partnership Agreement.
|_| Sole Proprietorship
Are you a certified Texas HUB?
| |_|Yes – Attach a copy of HUB certification form. |
| |_|No – Select all that apply if you fall into one or both of the categories below: |
|_|Minority Owned Business |_|Woman Owned Business
SECTION II-ELIGIBILITY REQUIRMENTS
(See Section 1.5 of the Open Enrollment)
1. Are you Licensed by HHSC as a Home and Community Support Services Agency (HCSSA) with the Personal Assistance Services category?
|_|Yes - If yes, attach a copy of the License and support of the counties authorized under the License.
|_|No - If no, applicant does not qualify to provide PAC services and do not submit an application (see Open Enrollment Section 1.5).
2. Have an HHSC contract to provide Primary Home Care (PHC) services?
|_|Yes - If yes, attach a copy of the contract or the HHS’ approval letter identifying the contract number, contract effective dates, and counties included under contract.
|_|No - If no, applicant does not qualify to provide PAC services and do not submit an application (see Open Enrollment Section 1.5).
3. Service Delivery Area Indicate which Counties in the DFPS Regions applying to provide PAC services and HHS service area designation (Form 3691).
DFPS Region 1 Service Delivery Area
☐ Check if applying for all Counties in Region 1
| ☐ Armstrong |
| ☐ Garza |
| ☐ Moore |
| ☐ Briscoe |
| ☐ Hale |
| ☐ Ochiltree |
| ☐ Castro |
| ☐ Hansford |
| ☐ Parmer |
| ☐ Childress |
| ☐ Hartley |
| ☐ Potter |
| ☐ Cochran |
| ☐ Hemphill |
| ☐ Randall |
| ☐ Collingsworth |
| ☐ Hockley |
| ☐ Roberts |
| ☐ Crosby |
| ☐ Hutchinson |
| ☐ Sherman |
| ☐ Dallam |
| ☐ King |
| ☐ Swisher |
| ☐ Deaf Smith |
| ☐ Lamb |
| ☐ Terry |
| ☐ Dickens |
| ☐ Lipscomb |
| ☐ Wheeler |
| ☐ Donley |
| ☐ Lubbock |
| ☐ Yoakum |
DFPS Region 2 Service Delivery Area
☐ Check if applying for all Region 2 Counties
| ☐ Archer |
| ☐ Foard |
| ☐ Runnels |
| ☐ Baylor |
| ☐ Hardeman |
| ☐ Scurry |
| ☐ Brown |
| ☐ Haskell |
| ☐ Shackelford |
| ☐ Callahan |
| ☐ Jack |
| ☐ Stephens |
| ☐ Clay |
| ☐ Jones |
| ☐ Stonewall |
| ☐ Coleman |
| ☐ Kent |
| ☐ Taylor |
| ☐ Comanche |
| ☐ Knox |
| ☐ Throckmorton |
| ☐ Cottle |
| ☐ Mitchell |
| ☐ Wichita |
| ☐ Eastland |
| ☐ Montague |
| ☐ Wilbarger |
DFPS Region 3 Service Delivery Area
☐ Check if applying for all Region 3 Counties
| ☐ Collin |
| ☐ Grayson |
| ☐ Parker |
| ☐ Cooke |
| ☐ Hood |
| ☐ Rockwall |
| ☐ Dallas |
| ☐ Hunt |
| ☐ Somervell |
| ☐ Denton |
| ☐ Johnson |
| ☐ Tarrant |
DFPS Region 4 Service Delivery Area
☐ Check if applying for all Region 4 Counties
| ☐ Anderson |
| ☐ Harrison |
| ☐ Red River |
| ☐ Bowie |
| ☐ Henderson |
| ☐ Rusk |
| ☐ Cherokee |
| ☐ Marion |
| ☐ Upshur |
| ☐ Delta |
| ☐ Morris |
| ☐ Van Zandt |
| ☐ Franklin |
| ☐ Panola |
| ☐ Wood |
DFPS Region 5 Service Delivery Area
☐ Check all if applying for all Region 5 Counties
| ☐ Angelina |
| ☐ Nacogdoches |
| ☐ San Augustine |
| ☐ Hardin |
| ☐ Newton |
| ☐ San Jacinto |
| ☐ Houston |
| ☐ Orange |
| ☐ Shelby |
| ☐ Jasper |
| ☐ Polk |
| ☐ Trinity |
| ☐ Jefferson |
| ☐ Sabine |
| ☐ Tyler |
DFPS Region 6 Service Delivery Area
☐ Check if applying for all Region 6 Counties
| ☐ Austin |
| ☐ Fort Bend |
| ☐ Matagorda |
| ☐ Brazoria |
| ☐ Galveston |
| ☐ Montgomery |
| ☐ Chambers |
| ☐ Harris |
| ☐ Walker |
| ☐ Colorado |
| ☐ Liberty |
| ☐ Waller |
☐ Wharton
DFPS Region 7 Service Delivery Area
☐ Check if applying for all Region 7 Counties
| ☐ Bastrop |
| ☐ Fayette |
| ☐ Llano |
| ☐ Bell |
| ☐ Freestone |
| ☐ Madison |
| ☐ Blanco |
| ☐ Grimes |
| ☐ McLennan |
| ☐ Bosque |
| ☐ Hamilton |
| ☐ Milam |
| ☐ Burleson |
| ☐ Hill |
| ☐ Robertson |
| ☐ Burnet |
| ☐ Lampasas |
| ☐ San Saba |
| ☐ Caldwell |
| ☐ Lee |
| ☐ Travis |
| ☐ Coryell |
| ☐ Leon |
| ☐ Washington |
| ☐ Falls |
| ☐ Limestone |
| ☐ Williamson |
DFPS Region 8 Service Delivery Area
☐ Check if applying for all Region 8 Counties
| ☐ Atascosa |
| ☐ Goliad |
| ☐ Maverick |
| ☐ Bandera |
| ☐ Gonzales |
| ☐ Medina |
| ☐ Bexar |
| ☐ Guadalupe |
| ☐ Real |
| ☐ Calhoun |
| ☐ Jackson |
| ☐ Uvalde |
| ☐ Comal |
| ☐ Karnes |
| ☐ Val Verde |
| ☐ De Witt |
| ☐ Kendall |
| ☐ Victoria |
| ☐ Edwards |
| ☐ Kinney |
| ☐ Zavala |
DFPS Region 9 Service Delivery Area
☐ Check all if applying for all Region 9 Counties
| ☐ Andrews |
| ☐ Howard |
| ☐ Reagan |
| ☐ Borden |
| ☐ Irion |
| ☐ Reeves |
| ☐ Coke |
| ☐ Kimble |
| ☐ Schleicher |
| ☐ Concho |
| ☐ Loving |
| ☐ Sterling |
| ☐ Crane |
| ☐ Martin |
| ☐ Sutton |
| ☐ Crockett |
| ☐ Mason |
| ☐ Terrell |
| ☐ Dawson |
| ☐ McCulloch |
| ☐ Tom Green |
| ☐ Gaines |
| ☐ Midland |
| ☐ Ward |
| ☐ Glasscock |
| ☐ Pecos |
| ☐ Winkler |
DFPS Region 10 Service Delivery Area
☐ Check if applying for all Region 10 Counties
| ☐ Brewster |
| ☐ El Paso |
| ☐ Jeff Davis |
| ☐ Culberson |
| ☐ Hudspeth |
| ☐ Presidio |
DFPS Region 11 Service Delivery Area
☐ Check if applying for all Region 11 Counties
| ☐ Aransas |
| ☐ Jim Hogg |
| ☐ Nueces |
| ☐ Bee |
| ☐ Jim Wells |
| ☐ Refugio |
| ☐ Brooks |
| ☐ Kennedy |
| ☐ San Patricio |
| ☐ Cameron |
| ☐ Kleberg |
| ☐ Starr |
| ☐ Duval |
| ☐ Live Oak |
| ☐ Webb |
| ☐ Hidalgo |
| ☐ Mc Mullen |
| ☐ Willacy |
☐ Zapata
4. Insurance. Indicate in the table below if requirements in Section 2.8 of the Open Enrollment. are met. See Section 2.8 of the Open Enrollment for more information.
Commercial General Liability:
Minimum combined bodily injury (including death) and property damage limits of $1,000,000 per occurrence, and $2,000,000 aggregate.
|_|Yes |_|No
Commercial Crime Policy with a 3rd Party and Employee Dishonesty or “Client Property” endorsement.
Minimum required coverage is $25,000.
|_|Yes |_|No
Contractor must submit insurance coverage documentation with the signed Contract. DFPS will not execute a Contract if this documentation is not provided or is found to not meet the insurance requirements.
SECTION III – CERTIFICATION
I certify that the information provided in this application is, to the best of my knowledge, complete and accurate; that the named legal entity has authorized me, as its representative, to submit this application; and that the legal entity complies with all terms of this Open Enrollment.
Signature of Authorized Representative
Date
Name of Authorized Representative (Printed) Title of Authorized Representative (Printed)
APPENDIX A – Attachments
1. In addition to this Application, the Applicant must submit the following forms and documents in the File Folders designated below.
2. Access the forms by the link or icon provided below by holding down the "Ctrl" key while clicking on the link.
3. Save forms in an electronic file by the File Folder numbers.
4. For the Application and the forms that require signature, print, sign and save in an electronic format.
FILE FOLDER 1: APPLICATION AND REQUIRED DOCUMENTS.
| ELECTRONIC FILE NAME |
| DESCRIPTION |
Required or If Applicable
| 01-Application |
| Application for Enrollment |
| Required |
| 01.A-License |
| HHSC License |
| Required |
| 01.B-Contract |
| HHSC Contract |
| Required |
| 01.C-Insurance |
| Insurance Document |
| Required |
| 01.D-DBA |
| Assumed Name Certificate Attachment |
| If applicable |
| 01.E-Incorporation |
| Certificate of Incorporation Attachment |
| If applicable |
| 01.F-LLC |
| LLC Articles of Formation Attachment |
| If applicable |
| 01.G-Partnership |
| Partnership Agreement Attachment |
| If applicable |
| 01.H-Partners |
| Names and addresses and for each partner |
| If applicable |
| 01.I-HUB |
| HUB Certification Form |
| If applicable |
FILE FOLDER 2: REQUIRED FORMS.
| Electronic File Name -Form Number |
| NAME |
| PURPOSE |
Document Location
| 74-176 |
| Vendor Direct Deposit Form |
| Direct Deposit Authorization |
| 74-176 |
| 1513 |
| Disclosure of Ownership and Control Interest Statement |
| Documents ownership and financial interest information |
| 1513 |
| 9007FFS |
| Internal Control Structure Questionnaire |
| Contractor's disclosure of internal controls. Instructions included |
9007FFS
| AP-152 |
| Application for Texas Identification Number/Additional Mailing Address |
| Application for Texas Identification Number |
| AP-152 |
HHS0014687
05/01/2024