ESBD_File_159970_HHS004774_Addendum 8_PAC Application_Form_Pkg 2_07.24.2023.docx

5.1 PAC OPEN ENROLLMENT APPLICATION, ATTACHMENTS

AND REQUIRED FORMS

INSTRUCTIONS

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

2. Applicant will submit Application in its entirety and all required documents in File Folders 1 and 2 in Appendix B to REGION12APSCONTRACTS@dfps.state.tx.us.

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

SECTION I – APPLICANT INFORMATION

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

Charter Number:

Attach a copy of Certificate of Incorporation

|_| Limited Liability Company (LLC)

Attach a copy of the Articles of Formation

|_| Sole Proprietorship

Are you a certified Texas HUB?

below:

|_|Minority Owned Business |_|Woman Owned Business

SECTION II-ELIGIBILITY REQUIRMENTS

(See Section 1.6 of the Open Enrollment)

1. Licensed as a Home and Community Support Services Agency (HCSSA) with the Personal Assistance Services category licensed by the Texas Health and Human Services Commission (HHSC)?

2. Have an HHSC contract to provide Primary Home Care (PHC) services?

3. Region specified in Service Delivery Area Detail.

Choose the DFPS Region where Personal Assistance Care Services will be provided.

10|_|

4. Insurance. Indicate in the table below if requirements are met.

Commercial General Liability:

Minimum combined bodily injury (including death) and property damage limits of $300,000 per occurrence, and $600,000 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

The Certificate of Insurance must be issued to DFPS or designate DFPS as the Certificate Holder.

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

ORGANIZATION OF APPLICATION

1. The Applicant does not execute and return the Personal Assistance Care Enrollment Sample Base Contract.

2. As part of their submission, Applicants must submit a completed application, forms and attachments, as applicable in the following order.

3. Access the forms by the link or icon provided below by holding down the "Ctrl" key while clicking on the link.

4. Save forms in an electronic file.

5. For the Application and the forms that require signature, print, sign and save in an electronic format.

APPENDIX B

APPLICATION, ATTACHMENTS AND REQUIRED FORMS

FILE FOLDER 1: Application

Required or If Applicable

FILE FOLDER 2: Required Forms

Document Location

Contractor's disclosure of internal controls. Instructions included.

9007FFS

HHS0004774

07/24/2023