ESBD_547773_1786134426674_Form 04-TWC VR Standards for Provider Cert(VR 3443).pdf
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- Attached to
- 3202600208 Open Enrollment (OE) for Assistive Technology (AT) Services for Customers with Visual Impairments
- Solicitation number
- 3202600208
- Issued by
- Texas
About this file
This document is a Standards for Providers Certification form (VR3443) issued by the Texas Workforce Commission (TWC) Vocational Rehabilitation Services division. The form serves as a certification and acknowledgment requirement for entities seeking to establish or maintain bilateral contracts with TWC to provide vocational rehabilitation services to VR customers. The form applies to new applications submitted through the Electronic State Business Daily (EBSD) posting, updates to existing provider information, and changes in provider qualifications. Completion requires entities to provide their legal business name, "doing business as" name, and either an Employer Identification Number or the last four digits of a sole proprietor's Social Security Number. The form must be completed in its entirety with all required signatures from the legally authorized representative of the applying entity.
The legally authorized representative must certify that the entity and its staff have read and will comply with the TWC VR Providers' Resource Page, TWC VR Standards for Provider Manual, and all applicable TWC VR forms. Additionally, the representative must certify compliance with any requirements specified in the relevant EBSD posting. The form acknowledges that failure to adhere to applicable standards outlined in the TWC VR Standards for Provider Manual, notices on the TWC VR Providers' Resource, form instructions, and EBSD posting requirements may result in adverse consequences including denial or recoupment of payments, suspension of service provision to VR customers, loss of contract awards, or rejection of applications. Supporting documentation must be retained by the applicant entity for their records, and submissions are directed to the appropriate Quality Assurance Specialist for VR, Regional Program Support Specialist, or Contract Manager as applicable.
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Text version
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
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