ESBD_520882_1779974001540_Attachment 08-VR3472 Contracted Service Modification.pdf

VR3472 (02/23) Contracted Service Modification Request Page 1 of 2

Texas Workforce Commission

Vocational Rehabilitation Services

Contracted Service Modification Request

Instructions:

A VR3472, Contracted Service Modification Request must be utilized and submitted in accordance with the following process:

1. the VR counselor will complete the VR3472;

2. prior to submitting, the VR counselor verifies the customer and provider agree with the modification;

3. the VR counselor will sign the VR3472 and obtain the provider’s legal authorized representative’s signature;

4. the VR counselor must enter a case note in ReHabWorks for the customer that explains and justifies the need for the modification including the content to questions asked within the form;

5. after the above steps are completed, VR counselor will send the VR3472 to the vrs.program.contract.approval@twc.texas.gov mailbox for approval using the naming convention in the subject line of the email: Region #_3472_provider’s name or customer’s case id;

6. the VR Standards Team or Subject Matter Expert will conduct a case review and coordinate the approval of the VR3472 obtaining VR Director signature;

7. VR standards team will ensure the final approved or not approved VR3472 is returned to VR counselor and will copy the Regional Quality Assurance Specialist or Regional Program Support Specialist;

8. the VR counselor will send the VR3472 to the provider and will file it in the customer paper file; and

9. providers will submit a copy of the approved VR3472 with applicable invoices.

Note: Update the customer’s IPE, when necessary, after VR3472 is approved.

Contractor Information

TWC contract number:

Texas Identification Number (TIN):

Legal name:

Doing Business As (DBA) name:

Director name:

Director’s email:

Director’s phone number:

Customer Identification Information

First name: Last name: Middle name:

VRS case ID: City:

Justification for Contracted Service Modification

Describe what contracted service(s) need to be modified:

Indicate the modification to the service description, process and procedure, or outcome required for payment that is necessary to meet the customer’s individual needs.

Provide a detailed justification on how this better meets the customer’s needs and achievement of the customer’s employment or independent living goal (include specific details and dates).

SAMPLE

mailto:vrs.program.contract.approval@twc.state.tx.us

VR3472 (02/23) Contracted Service Modification Request Page 2 of 2

Disability and supports need(s):

Background information and circumstances:(include how the employment barrier and/or circumstances of the customer are being addressed)

Justify the modification request

(How will the employment or disability barriers be addressed and how will the request assist the customer in achievement of his/her Individual Employment Plan (IPE) or Independent Living Plan (ILP)):

VR Counselor Acknowledgment

By typing my name below, I have verified the information on the request is accurate.

Yes, the required ReHabWorks case note has been entered.

VR counselor’s Typed Name:

Region # Date:

Entity’s Legal Authorized Representative Signature

A legally authorized representative is the person who is authorized to sign contracts and other official documents for the entity.

By signing below, I, the entity’s legally authorized representative, acknowledge agreement with the information contained in the Contracted Service Modification form. (see VR-SFP 3 on Signatures)

Entity’s Legally Authorized Representative Typed or Printed Name:

Entity’s legally authorized representative’s digital or handwritten signature:

X Date:

VR Division Director Review and Signature

By signing my name below, I am providing my approval or denial of the contract modification request as indicated:

Approve request above Deny request above

VR Division Director typed or signed name:

X

Date:

Additional Comments

When needed, add additional comments, date and initial each entry:

State Office Use Only

ReHabWorks Case and Contracted Service Modification Request reviewed

Comment, if any:

SAMPLE