ESBD_File_199760_HHS0007894_Package 2_OE_Application and Service Area Forms.docx

5.1 HOSPITAL SITTING SERVICES OPEN ENROLLMENT

APPLICATION

INSTRUCTIONS

5.1.1 Application must be completed and signed in Section 3 (Certification) for it to be accepted by DFPS.

5.1.2 Applicant will submit Application and all required documents in the format and order described in Appendix A to the Point of Contact in Open Enrollment Section 1.2.

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

Addendum 6—July 12, 2023 Addendum 5 Addendum 4- July 7, 2020 Addendum 3 – June 16, 2020 Addendum 2 – June 11, 2020 Addendum 1 – May 19, 2020 Texas Department of Family & Protective Services Hospital Sitting Services Enrollment Number HHS0007894

Instructions

07-12-2023

1. APPLICANT INFORMATION

Vendor ID Number:

Federal ID Number – If different from Vendor ID:

Applicant:

Parent Organization:

Doing Business As Name (DBA) or Parent Organization – 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

Type of Applicant – Check appropriate box(es) and attach documentation as indicated

|_| Sole Proprietorship

Charter Number:

Attach a copy of Certificate of Incorporation

below:

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

Person Authorized to Sign Contract:

Contact for Service Delivery:

Contact for Invoicing:

2. ELIGIBILITY REQUIRMENTS

(See Section 2.12 of the Open Enrollment)

2.1 Does Applicant have two years of full-time relevant service management experience at the time of this Application is submitted?

2.2 Does Applicant have two years relevant financial Management experience at the time of this Application is submitted?

2.3 Does Applicant meet the insurance requirements in Section 2.15 of the Open Enrollment?

3. SERVICE DELIVERY AREA

(See Section 2.2 of the Open Enrollment)

Region(s) to be Served:

Applicant must mark with a “√” next to the Region(s), and Catchment Area (where applicable) for Region 4. DFPS is not accepting Applications in Regions 2 and 3b because these Regions are being served by a Community Based Care provider. See below for more information on the counties in each Region.

· Region 1 – All Counties in Region 1.

· Region 2 – Not Accepting Applications.

· Region 3 – All Counties in Region 3 except for 3b Catchment Area, which are Palo Pinto, Parker, Tarrant, Erath, Hood, Somervell, and Johnson counties.

· Region 4 – Catchment Area 1: All Counties in Region 4.

· Region 4 – Catchment Area 2: Only for children hospitalized in Arkansas or Louisiana.

· Region 5 – All Counties in Region 5.

· Region 6 – All Counties in Region 6.

· Region 7 – All Counties in Region 7.

· Region 8 – All Counties in Region 8.

· Region 9 – All Counties in Region 9.

· Region 10 – All Counties in Region 10.

· Region 11 – All Counties in Region 11.

4. 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)

Texas Department of Family & Protective Services Hospital Sitting Services Enrollment Number HHS0007894

Application

Appendix A – Application Instructions

1. Applicant must submit a completed Application and Required Forms, as applicable, in the order listed below for File Folder 1 and File Folder 2.

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

3. Save forms in an electronic file.

4. For the Application and the forms that require signature, print, sign and scan in an electronic format. Scanned documents must be clear and legible.

5. Attach File Folders 1 and 2 to email and submit the completed Application to the Point of Contact listed in the Open Enrollment Section 1.2.

Appendix B – Required Forms

File Folder 1: Application

Required or If Applicable

File Folder 2: Required Forms

The following forms are located on the DFPS public website, Doing Business with DFPS, Contracting Forms: https://www.dfps.state.tx.us/Doing_Business/forms.asp

attachments must be provided as applicable.

The following form is located on the DFPS public website, Doing Business with DFPS, Contracting Forms, Regional CPS Contracting Forms, General Documents:

https://www.dfps.state.tx.us/Doing_Business/Purchased_Client_Services/Regional_CPS_Contracts/forms.asp

NOTE: Contractor must submit documentation of organizational qualifications (financial and service management) and direct service staff qualifications for each person listed on Form PCS-102 who will provide the services identified in this open enrollment. Refer to contract sections 2.12 and 2.13 for a list of qualifications.