ESBD_File_279550_HHS0011952_Application_Required Forms_Pkg 2_SAS_FY23_032522.docx

5.1 SUBSTANCE ABUSE SERVICES OPEN ENROLLMENT

APPLICATION

INSTRUCTIONS

5.1.1 Application must be completed and signed in Section 5 (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.

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 2.16 Contractor Qualifications of the Open Enrollment)

2.1 Does Applicant hold a valid and current Texas State Licensure and Credentials, in Section 2.16.2, at the time this Application is submitted?

2.2 Does Applicant meet the insurance requirements in Section 2.17 of the Open Enrollment?

3. SERVICES TO BE PROVIDED

Contractor must provide Substance Abuse Assessment and Treatment Services as specified in Provider Enrollment HHS00011952. Contractor must provide all Support Services specified in HHS0011952 upon DFPS request.

Substance Abuse Assessment and Treatment Services

Individual and Group Counseling

Diagnostic Consultation Translator & Interpreter As requested by DFPS

4. SERVICE DELIVERY LOCATIONS

a. You must determine which counties will be served and mark them in Attachment A-4 Service Delivery Areas. Contractor must provide services within each county selected.

b. Will you, your staff, or subcontractors be delivering services from established office sites other than the location listed in Section c. (below) of this application?

|_| Yes |_| No

If yes, services from these satellite locations are to be billed as In-Office. Designate any satellite office on Attachment A-4 Service Delivery Areas.

c. Indicate locations in which the Contractor is willing to provide services.

|_| In-Office |_| Out-of-Office |_| Home-Based (client's home)

d. Will you, your staff, or other subcontractors be delivering telehealth services in addition to at least one of the locations listed in Sections a - c of this application? Note: If you elect to provide telehealth services, you must also provide either In-Office, Out-of-Office or Home-based services in the same region(s) and counties in which you are electing to provide telehealth services.

|_| Yes |_| No

NOTE: If yes, telehealth services must be billed as In-Office.

5. 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 Substance Abuse Services Enrollment Number HHS0011952

Application

Attachment A-4 Service Delivery Area

Service Delivery Area Counties To Be Served – Region 1

Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.

Regional Counties

☐ Armstrong

☐ Hockley

☐ Bailey

☐ Hutchinson

☐ Briscoe

☐ King

☐ Carson

☐ Lamb

☐ Castro

☐ Lipscomb

☐ Childress

☐ Lubbock

☐ Cochran

☐ Lynn

☐ Collingsworth

☐ Moore

☐ Crosby

☐ Motley

☐ Dallam

☐ Ochiltree

☐ Deaf Smith

☐ Oldham

☐ Dickens

☐ Parmer

☐ Donley

☐ Potter

☐ Floyd

☐ Randall

☐ Garza

☐ Roberts

☐ Gray

☐ Sherman

☐ Hale

☐ Swisher

☐ Hall

☐ Terry

☐ Hansford

☐ Wheeler

☐ Hartley

☐ Yoakum

☐ Hemphill

Service Delivery Area Counties To Be Served – Region 2

Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.

Regional Counties

☐ Archer

☐ Kent

☐ Baylor

☐ Knox

☐ Brown

☐ Mitchell

☐ Callahan

☐ Montague

☐ Clay

☐ Nolan

☐ Coleman

☐ Runnels

☐ Comanche

☐ Scurry

☐ Cottle

☐ Shackelford

☐ Eastland

☐ Stephens

☐ Fisher

☐ Stonewall

☐ Foard

☐ Taylor

☐ Hardeman

☐ Throckmorton

☐ Haskell

☐ Wichita

☐ Jack

☐ Wilbarger

☐ Jones

☐ Young

Service Delivery Area Counties To Be Served – Region 3

Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.

Regional Counties

☐ Collin

☐ Johnson

☐ Cooke

☐ Kaufman

☐ Dallas

☐ Navarro

☐ Denton

☐ Palo Pinto

☐ Ellis

☐ Parker

☐ Erath

☐ Rockwall

☐ Fannin

☐ Somervell

☐ Grayson

☐ Tarrant

☐ Hood

☐ Wise

☐ Hunt

Service Delivery Area Counties To Be Served – Region 4

Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.

Regional Counties

☐ Anderson

☐ Marion

☐ Bowie

☐ Morris

☐ Camp

☐ Panola

☐ Cass

☐ Rains

☐ Cherokee

☐ Red River

☐ Delta

☐ Rusk

☐ Franklin

☐ Smith

☐ Gregg

☐ Titus

☐ Harrison

☐ Upshur

☐ Henderson

☐ Van Zandt

☐ Hopkins

☐ Wood

☐ Lamar

Service Delivery Area Counties To Be Served – Region 5

Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.

Regional Counties

☐ Angelina

☐ Polk

☐ Hardin

☐ Sabine

☐ Houston

☐ San Augustine

☐ Jasper

☐ San Jacinto

☐ Jefferson

☐ Shelby

☐ Nacogdoches

☐ Trinity

☐ Newton

☐ Tyler

☐ Orange

Service Delivery Area Counties To Be Served – Region 6

Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.

Regional Counties

☐ Austin

☐ Liberty

☐ Brazoria

☐ Matagorda

☐ Chambers

☐ Montgomery

☐ Colorado

☐ Walker

☐ Fort Bend

☐ Waller

☐ Galveston

☐ Wharton

☐ Harris

Service Delivery Area Counties To Be Served – Region 7

Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.

Regional Counties

☐ Bastrop

☐ Hill

☐ Bell

☐ Lampasas

☐ Blanco

☐ Lee

☐ Bosque

☐ Leon

☐ Brazos

☐ Limestone

☐ Burleson

☐ Llano

☐ Burnet

☐ Madison

☐ Caldwell

☐ McLennan

☐ Coryell

☐ Milam

☐ Falls

☐ Mills

☐ Fayette

☐ Robertson

☐ Freestone

☐ San Saba

☐ Grimes

☐ Travis

☐ Hamilton

☐ Washington

☐ Hays

☐ Williamson

Service Delivery Area Counties To Be Served – Region 8

Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.

Regional Counties

☐ Atascosa

☐ Karnes

☐ Bandera

☐ Kendall

☐ Bexar

☐ Kerr

☐ Calhoun

☐ Kinney

☐ Comal

☐ La Salle

☐ De Witt

☐ Lavaca

☐ Dimmit

☐ Maverick

☐ Edwards

☐ Medina

☐ Frio

☐ Real

☐ Gillespie

☐ Uvalde

☐ Goliad

☐ Val Verde

☐ Gonzales

☐ Victoria

☐ Guadalupe

☐ Wilson

☐ Jackson

☐ Zavala

Service Delivery Area Counties To Be Served – Region 9

Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.

Regional Counties

☐ Andrews

☐ Mason

☐ Borden

☐ McCulloch

☐ Coke

☐ Menard

☐ Concho

☐ Midland

☐ Crane

☐ Pecos

☐ Crockett

☐ Reagan

☐ Dawson

☐ Reeves

☐ Ector

☐ Schleicher

☐ Gaines

☐ Sterling

☐ Glasscock

☐ Sutton

☐ Howard

☐ Terrell

☐ Irion

☐ Tom Green

☐ Kimble

☐ Upton

☐ Loving

☐ Ward

☐ Martin

☐ Winkler

Service Delivery Area Counties To Be Served – Region 10

Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.

Regional Counties

☐ Brewster

☐ Hudspeth

☐ Culberson

☐ Jeff Davis

☐ El Paso

☐ Presidio

Service Delivery Area Counties To Be Served – Region 11

Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.

Regional Counties

☐ Aransas

☐ Live Oak

☐ Bee

☐ McMullen

☐ Brooks

☐ Nueces

☐ Cameron

☐ Refugio

☐ Duval

☐ San Patricio

☐ Hidalgo

☐ Starr

☐ Jim Hogg

☐ Webb

☐ Jim Wells

☐ Willacy

☐ Kenedy

☐ Zapata

☐ Kleberg

Satellite Offices and Additional Office Information:

Please provide a schedule in the table(s) below indicating days and times routinely available to provide services at each service location. These represent only routine days and times. Applicant will be expected to adjust schedule to accommodate the needs of clients and DFPS. Refer to PEN Section 2.5 for additional information. Use additional copies of this section, as necessary, to provide complete information.

1.

HOURS

2.

HOURS

3.

HOURS

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 and Service Delivery Area

Required or If Applicable

File Folder 2: Supporting Documentation

File Folder 3: 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

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

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