ESBD_367425_1720549618392_5.1 New Applicant Application.docx

5.1 SIL NEW APPLICANT OPEN ENROLLMENT APPLICATION

INSTRUCTIONS

1. Applicant must read all of the Open Enrollment posted on the ESBD or the HHS Enrollment Sites before completing this Application.

2. The Application must be completed and signed in Section V (Certification) for it to be accepted by DFPS.

3. The Application must be complete for it to be accepted by DFPS. DFPS considers a complete answer to be a written response. Responding with “Not Applicable” is only an appropriate response when a question or form does not apply to Applicant.

4. Applicant will provide the information in the body of the Application unless otherwise instructed to include it as an attachment (See File Folder 2 in Appendix A below).

5. Applicant will complete the forms listed See Required Forms (See File Folder 3 in Appendix A below).

6. Applicant will submit all Contract Application files and documents to DFPS24HourResidentialAppliations@dfps.texas.gov.

7. If DFPS has difficulty accessing the Applicant’s documents, the Applicant will be required to re-submit documents as directed by DFPS.

8. For Enhanced Case Management Services (ECM) (see Section 1.1.2 and 1.4.4 of the Open Enrollment)

· If you have a current SIL contract and want to provide ECM services, then you will only have to complete Addendum to the SIL Open Enrollment Application to Provide ECM Services (See Appendix B below).

· If you are a new applicant and want to apply to provide ECM, complete all sections of the Application including the areas that are marked with ECM.

SECTION I – APPLICANT INFORMATION

If Applicant is not already a vendor with the State of Texas, leave blank and ensure completion of Form AP-152 found in Appendix B File Folder 3

Doing Business As Name (DBA) or Parent Organization- Indicate if different from Legal Name above Attach applicable documents as provided for in File Folder A of Appendix B

Mailing Address - If different from Office Address above Applicant:

Parent Organization:

Federal ID Number – If different from Vendor ID Applicant:

Parent Organization:

Social Security Number - If applying as Individual/Sole Proprietor

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 boxes and attach documentation as indicated in File Folder 2 of Appendix B below

Are you applying to provide services to DFPS without payment (No-Pay Contract)? |_|Yes |_|No

Filing Number or equivalent:

Attach a copy of Certificate of Formation or equivalent document

|_| Limited Liability Company (LLC) Attach a copy of the Certificate of Formation or equivalent document

Attach a list of names, addresses and Social Security numbers for each partner If Partnership – Do you have:

|_|Yes |_|No Partnership Agreement |_|Yes |_|No Signatory Assignment

If Yes is checked above, attach a copy

|_| Sole Proprietorship

If Sole Proprietorship Provide date of birth:

SECTION II - ELIGIBILITY REQUIRMENTS

1. Is the Applicant debarred from receiving any federal or state funds at the time of the Application?

|_| Yes |_| No

2. Has the Applicant had a contract for Residential Child Care services or other transitional living services for young adults (similar to what is sought in this Open Enrollment) that was non-renewed or terminated by DFPS or any other private party or governmental entity within the last five years?

|_| Yes |_| No

If yes, please complete a and b:

a. Provide the name of the program or entity, date of the non-renewal or termination, the contract number, and list the factors that contributed to DFPS or any other private party or governmental entity taking that action; and

Answer:

b. Describe in detail the actions taken by your SIL Program to remedy each factor that contributed to that non-renewal or termination.

Answer:

3. The Applicant must have a Case Manager (See Section 1.5.1(h) of the Open Enrollment) that oversees the Contractor’s SIL Program and Settings. You will attach the required documentation in Appendix B’s File Folder 2.

4. FOR ECM ONLY - If applying to also provide ECM, the Applicant has a Case Manager that also meets the requirements for the Trauma Informed Care and Psychotropic Medication Trainings as provided for in Section 1.5.1(h)(4) of the Open Enrollment. You will attach the required documentation in Appendix B’s File Folder 2.

SECTION III – INSURANCE

Review Sections 1.5.1(e), 1.6.2 (b), and 1.7.1(c) of the Open Enrollment, Section II(E) of DFPS Vendor Uniform Terms and Conditions, and Attachment 5.3 Special & Programmatic Conditions-SIL.

Indicate below that you meet these requirements.

Commercial Crime Insurance or equivalent insurance with 3rd Party endorsement & Employee Dishonesty endorsement: |_|Yes |_|No

Commercial General Liability or equivalent insurance: |_|Yes |_|No

If "No" is checked for any insurance named above, the 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.

If “Yes” is checked for any insurance named above, the Contractor must submit insurance coverage documentation prior to contract execution.

The Contractor must submit insurance coverage documentation for both types listed above 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 IV - SERVICE AREA AND SETTING TYPES

APPLICATIONS NOT ACCEPTED – New Applications with all capacity located within a CBC catchment area will not be accepted. For a list of CBC catchments, see the Community-Based Care page on the DFPS website (Community-Based Care - Community Areas (texas.gov).

Review Section 1.5 of the Open Enrollment for qualifications and Section 2.8 of the Open Enrollment for setting types and Section III Programmatic Conditions of Attachment 5.3 (Subsection C) for Minimum Requirements.

1. Indicate below the Setting Type and Region of the physical location where you are applying to provide SIL services and setting(s), and if applicable, indicate the Regions and/or Settings that you are applying to provide ECM.

2. DFPS Regions below are the ones in which DFPS is currently accepting Applications. For the other Regions, SIL and ECM will be contracted through Community Based Care (CBC) providers (See Section 1.5.1(k) of the Open Enrollment).

a. |_| Apartment Setting

8A-Bexar County

Apartment Name:

Apartment Address:

b. |_| College Dorm Setting (ECM is not allowed in this Setting)

College Name:

c. |_| Non-College Dorm Setting

8A-Bexar County

8A-Bexar County

Non-College Dorm Address:

d. |_| Shared Housing Setting

8A-Bexar County

Shared Housing Address:

e. |_| Host Home Setting (Only apply for this Setting if you have an active DFPS Residential Child Care Contract that is not in provisional status).

Host Home Address:

3. Does your Setting’s living and sleeping areas meet the requirements of Open Enrollment and Attachment 5.3 Special & Programmatic Conditions-SIL Section III(C)?

|_|Yes |_|No

4. Attach floor plan for each of the setting(s) for which you are applying to use in your SIL Program. Provide the dimensions of the living and sleeping areas, separate versus shared spaces, privacy, bathroom, kitchen or laundry.

SECTION IV- SIL PROGRAM REQUIREMENTS

1. Provide in a narrative format how your SIL Program will meet the requirements in Section 2.2 of the Open Enrollment; and do not cut and paste from it as it may be considered an incomplete response.

a. How your SIL Program will provide services to young adults;

b. How these SIL services will be coordinated and implemented with CPS Caseworkers and Regional staff, including participating in conference calls and meetings as requested by DFPS (Section 2.5.1(g) of the Open Enrollment);

c. Procedures for elevating concerns about young adults to DFPS and maintaining compliance with notification requirements (See Attachment 5.3 Section III);

d. If you are applying to provide ECM, explanations on how you would meet the heightened needs and requirements for youth in ECM;

e. Other supporting programmatic information; and

f. Transportation must be made available when distance or access to public transportation exceeds one mile for education, training, work, grocery store, laundry facilities, bus or metro stop, library or other community resources. If not available, DFPS may grant a waiver of this requirement upon receipt of Contractor’s plan to provide transportation.

SECTION V - 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 requirements of this Open Enrollment.

Name of Authorized Representative (Printed)

Title of Authorized Representative (Printed)

APPENDIX A -

APPLICATION, ATTACHMENTS AND REQUIRED FORMS

FILE FOLDER 1: Application

Required or If Applicable

FILE FOLDER 2: Attachments

Required or If Applicable

FILE FOLDER 3: Required Forms

Document Location

F-500-2970c.pdf

Criminal history and DFPS check for Executive Director, CEO, Comptroller and CFO, if applicable

F-500-2971c.pdf

9007RCC.doc

APPENDIX B -

ADDENDUM TO THE SIL OPEN ENROLLMENT APPLICATION TO PROVIDE ECM SERVICES

1. Legal Name of Entity applying to add ECM Services:

Name of person coordinating addition of ECM Services:

Phone number:

Email address:

Name of Case Manager:

2. Has any information from SECTION I APPLICANT INFORMATION for the Entity changed since SIL Application was received? If yes, provide an explanation of these changes.

3. To fulfill SECTION II- ELIGIBILITY REQUIRMENTS #4, submit current training certificates for Trauma Informed Care and Psychotropic Medication.

4. Are there any currently operating SIL locations and settings that the Entity operates where you will NOT be adding ECM? If so, state locations and settings where you will NOT be adding ECM.

5. To fulfill SECTION IV- SIL PROGRAM REQUIREMENTS #1(d), provide a narrative of how you will meet the heightened needs and requirements for youth in ECM, specifically addressing items included in:

· 1.4.5(d)

· 2.4.3

· 2.5.2

DFPS SIL Open Enrollment