ESBD_488564_1770669782109_Form 4 - TWC VR Standards for Provider Certification (VR 3443).pdf

VR3443 (03/20) Standards for Providers Certification Page 1 of 2

Texas Workforce Commission Vocational Rehabilitation Services

TWC VR Standards for Providers Certification

Instructions:

• For response to an Electronic State Business Daily (EBSD) posting, follow the instructions in the

ESBD posting, otherwise submit updated forms to the Quality Assurance Specialist for VR (Q) or Regional Program Support Specialist (RPSS) and Contract Manager.

• Follow instructions on the form and in the TWC VR Standards for Providers.

• Type all information on form using a computer and get all required signatures.

• Complete all sections of the form. Record “N/A” (not applicable) if a question does not apply.

• Keep a copy of your submitted form with attachments and supporting documentation for your records.

Reason for Submission Date of submission:

Application package Solicitation ID:

Update of information due to change in information on file. For example, qualifications change.

Other: Specify:

Entity’s Information Entity: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers.

Entity’s legal name:

Entity’s “doing business as” (DBA) name:

Provide at least one of the following:

Employer Identification Number (EIN) (9 digits, issued by IRS):

Last four digits of the sole proprietor’s Social Security Number:

VR3443 (03/20) Standards for Providers Certification Page 2 of 2

TWC Acknowledgment and Signature This acknowledgment is applicable to, and shall be considered active for, the following purposes:

• Processing of the respondent’s application

• Execution of the initial award, if applicable

• Continuation of the contract life through subsequent execution of renewals and/or amendments and/or updating information on file with TWC as applicable.

I, the legally authorized representative of the entity named in this application:

• certify that the entity staff and I have read and will abide by the TWC VR Providers’ Resource

Page, TWC VR Standards for Provider Manual and TWC VR forms;

• certify that that the entity will abide by any requirements prescribed in the Electronic State

Business Daily (EBSD) posting for which the entity applied; and

• acknowledge that failure to follow applicable standards in the TWC VR Standards for Provider

Manual, notices or publications on the TWC VR Providers’ Resource, instructions on TWC VR forms and requirement in the EBSD posting associated with the entity could cause adverse consequences for the entity, such as denial of payments, recoupment of payments, suspension of service provision to VR customers, loss of an awarded contract or processing of an application from an EBSD posting.

Legally authorized representative’s printed name:

Title:

Legally authorized representative’s handwritten signature:

X

Date:

Agency Use Only Comments:

http://www.twc.state.tx.us/partners/vocational-rehabilitation-providers-resources http://www.twc.state.tx.us/partners/vocational-rehabilitation-providers-resources http://www.twc.state.tx.us/partners/vocational-rehabilitation-standards-providers-manual http://www.twc.state.tx.us/forms/index.html