Edit, Download, and Sign the Provider Agreement Community Services Contract
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To fill out this form, start by gathering all required information about your organization. Ensure that all details are accurate and complete. Review the document for any specific instructions before submission.
How to fill out the Provider Agreement Community Services Contract?
1
Gather necessary documentation and details.
2
Complete all required fields accurately.
3
Review for accuracy and completeness.
4
Submit through the specified method.
5
Retain a copy for your records.
Who needs the Provider Agreement Community Services Contract?
1
Health care providers applying for services.
2
Organizations looking to enter into contracts with HHSC.
3
Business entities in the healthcare sector seeking compliance.
4
Individuals managing community service contracts.
5
Providers needing to align with Texas health regulations.
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What are the instructions for submitting this form?
To submit this form, please email it to contracts@hhsc.state.tx.us or fax to 512-424-6500. Physical submissions can be sent to the Texas Health and Human Services Commission, Provider Services, P.O. Box 149030, Austin, TX 78714-9030. Ensure all documentation is completed and attached as required.
What are the important dates for this form in 2024 and 2025?
Important dates for the contract include the effective date starting from January 1, 2022, and expiring on December 31, 2025. Ensure to cross-check these dates in any agreements for compliance. Submissions should be made within stipulated timelines to avoid disruption of services.
What is the purpose of this form?
The primary purpose of this form is to establish a legal framework for the contractor to provide services under the Texas Health and Human Services Commission. It ensures that contractors comply with state and federal regulations while providing care services. By filling out this form, organizations agree to uphold the standards and guidelines set forth by HHSC.
Tell me about this form and its components and fields line-by-line.
- 1. Contractor's Legal Name: The official registered name of the contractor.
- 2. DBA Name: The name under which the contractor operates, if applicable.
- 3. Email: The contact email of the contractor's signature authority.
- 4. Phone: The primary contact number.
- 5. Physical Address: The complete address of the contractor.
- 6. Taxpayer ID: The identification number for the contractor for tax purposes.
- 7. NPI/API: National or Atypical Provider Identifier if applicable.
- 8. Contract Dates: The effective and expiration dates of the contract.
- 9. Contract Type: The specific type of services being contracted.
What happens if I fail to submit this form?
Failure to submit this form can lead to delays in service provision and compliance issues with state regulations. Contractors may face penalties or be unable to receive contract funding until the form is properly submitted.
- Service Delays: Inability to provide necessary services due to incomplete documentation.
- Compliance Penalties: Potential fines or penalties assessed by the state for non-compliance.
- Funding Issues: Contractors may lose eligibility for funding opportunities pending correct submission.
How do I know when to use this form?
- 1. Contract Application: Use this form when applying for a contract with HHSC.
- 2. Service Agreement Documentation: Necessary for documenting agreements to provide services.
- 3. Regulatory Compliance: Ensure compliance with health and human services regulations.
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