Application Packet Checklist

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Form 5873
December 2016-E
Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Waiver Program Provider
Application Packet Checklist
Legal Entity Name
Doing Business As (DBA), if applicable
1. The submitted application packet must be typed or legibly printed. Please do not submit form instructions with your
completed application packet.
2. The following apply to all entity types, and your completed application must include all of the items listed below. Please
check boxes to indicate you have complied with the requirements.
Form 5873, Application Packet Checklist
Form 3681, Community Services Contract Application
Form 3691-A, Service Area Designation HCS, TxHmL, CDS and TAS
Form 5871, Disclosure of Ownership and Control Interest Statement or
Form 5871-S, Disclosure of Ownership and Control Statement - Short Form
Form 5875, HCS Waiver Program Self-Assessment Certification
Form 5920, TxHmL Waiver Program Self-Assessment Certification (if applicable)
Form 2031, Governing Authority Resolution – Business Organization (notarized) (not required for Sole Proprietor)
Form 4732, Nongovernmental Contractor Certification
Form 4732-A, Nongovernmental Contractor Certification (Part II) (if applicable)
Copy of Verification of the Employer Identification Number (EIN) (IRS Form CP-575 or Letter 147c)
Copy of National Provider Identifier (NPI) conformation e-mail or letter, as applicable
Data Use Agreement (See: )
HHS Information Security and Privacy Initial Inquiry
(See: )
Copies of Receipts for Criminal History Records Requests
Resume of Program Manager, individual named in Section 8b of Form 3681
Three written, verifiable, signed professional letters of reference attesting to the required work experience of the
Program Manager, individual named in Section 8b of Form 3681
Note: If all three references do not specifically attest to the required work experience, the application packet will be
rejected.
Copies of Pre-Application Orientation (PAO) Certificates of Completion DADS requires the following person(s) to
complete all modules with a score of 70% or higher:
Owner, CEO or Contact Person(s), named in Section 8a of Form 3681
Program Manager, named in Section 8b of Form 3681
3. The following apply by entity type. Please check the correct entity type and submit with the application packet all of the
documentation listed below for that entity type.
Sole Proprietorship
Copy of owner's Social Security Card
Copy of owner's Driver’s License
Certificate of Assumed Business Name as filed with County

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