INSTRUCTIONS - Texas



5.1 MENTAL HEALTH PROVIDER ENROLLMENT APPLICATION, ATTACHMENTS AND REQUIRED FORMSINSTRUCTIONSIf applying for more than one region, only use one Application and indicate on that Application what you are applying to provide services in. Application must be completed and signed in Section V (Certification) for it to be accepted by DFPS. Applicant will submit Application in its entirety and all required documents in File Folders 1 and 2 in Appendix B to REGION12APSCONTRACTS@dfps.. 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 INFORMATIONLegal Name of Applicant FORMTEXT ?????Office Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Mailing Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Phone FORMTEXT ?????Contact Person FORMTEXT ?????Title FORMTEXT ?????Contact's E-mail FORMTEXT ????Contact Person’s Phone FORMTEXT ?????Authorized Signatory FORMTEXT ?????Title FORMTEXT ?????Authorized Signatory E-mail FORMTEXT ????Authorized Signatory Phone FORMTEXT ?????Billing Person FORMTEXT ?????Title FORMTEXT ?????Billing Person’s E-mail FORMTEXT ????Billing Person’s Phone FORMTEXT ?????Doing Business As Name (DBA) or Parent Organization Indicate if different from Legal Name above: FORMTEXT ?????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 OrganizationMailing Address - If different from Office Address aboveApplicant: FORMTEXT ?????Parent Organization: _ FORMTEXT ?????Vendor ID Number: FORMTEXT ?????Federal ID Number – If different from Vendor IDApplicant: FORMTEXT ?????Parent Organization: FORMTEXT ?????Name of Person Authorized to Sign Contract FORMTEXT ?????Title FORMTEXT ?????Phone Number: FORMTEXT ?????Email: FORMTEXT ?????Name of Person Responsible for Billing FORMTEXT ?????Title FORMTEXT ?????Phone Number: FORMTEXT ?????Email: FORMTEXT ?????Type of Applicant – Check appropriate box(es) and attach documentation as indicated FORMCHECKBOX Governmental EntityDo you have taxing authority? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Private Corporation FORMCHECKBOX For Profit FORMCHECKBOX Non-ProfitState of Incorporation: FORMTEXT ?????Charter Number: FORMTEXT ?????Attach a copy of Certificate of Incorporation FORMCHECKBOX Limited Liability Company (LLC) Attach a copy of the Articles of Formation FORMCHECKBOX Partnership FORMCHECKBOX Limited FORMCHECKBOX GeneralAttach a list of names, addresses for each partner and provide a copy of the Partnership Agreement. FORMCHECKBOX Sole ProprietorshipAre you a certified Texas HUB? FORMCHECKBOX Yes – Attach a copy of HUB certification form. FORMCHECKBOX No – Select all that apply if you fall into one or both of the categories below: FORMCHECKBOX Minority Owned Business FORMCHECKBOX Woman Owned BusinessSECTION II-SERVICE DELIVERY AREASFor this Open Enrollment, DFPS is seeking the following Mental Health Professionals in Regions 4, 5 and 11 (see also Sections 1.5.4 and 1.6.1 in the Open Enrollment). Credentials by Region - Mental Health AssessmentsDFPS Regioins4511PsychologistXXXLicensed Clinical Social WorkerXXXLicensed Master Social WorkerXLicense Professional Counselor??XMental Health Assessments. Based on the chart in #1 above, select the Regions and if applicable, the counties that you are applying to provide Mental Health Assessments in if awarded a contract for this Open Enrollment. Region 4 Counties ? All Counties? Anderson? Panola? Bowie? Rains? Camp? Red River? Cass? Rusk? Cherokee? Smith? Delta? Titus? Franklin? Upshur? Gregg? VanZandt? Harrison? Wood? Henderson? ? Hopkins? ? Lamar? ? Marion? ? Morris? Region 5 Counties ? All Counties? Angelina? San Augustine? Hardin? San Jacinto? Houston? Shelby? Jasper? Trinity? Jefferson? Tyler? Nacogdoces? Newton? Orange? Polk? SabineRegion 11 Counties ? All Counties? Aransas? Live Oak? Bee? McMullen? Brooks? Nueces? Cameron? Refugio? Duval? San Patricio? Hidalgo? Starr? Jim Hogg? Webb? Jim Wells? Willacy? Kenedy? Zapata? KlebergSECTION IV -INSURANCEIndicate in the table below if requirements are mercial General Liability: Minimum combined bodily injury (including death) and property damage limits of $300,000 per occurrence, and $600,000 aggregate. FORMCHECKBOX Yes FORMCHECKBOX NoProfessional Liability Insurance:Minimum required coverage $1,000,000 occurrence and $2,000,000 aggregate. FORMCHECKBOX Yes FORMCHECKBOX NoCommercial Crime Policy with a 3rd Party and Employee Dishonesty or “Client Property” endorsement.*Business entities with no employees are not required to obtain Commercial Crime insurance. Minimum required coverage is $25,000. FORMCHECKBOX Yes FORMCHECKBOX NoThe 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 V – CERTIFICATIONI 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 RepresentativeDate FORMTEXT ?????Name of Authorized Representative (Printed) FORMTEXT ?????Title of Authorized Representative (Printed) FORMTEXT ?????APPENDIX AORGANIZATION OF APPLICATION1. The Applicant does not execute and return the Mental Health 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 BAPPLICATION, ATTACHMENTS AND REQUIRED FORMS FILE FOLDER 1: ApplicationELECTRONIC FILE NAMEDESCRIPTIONRequired or If Applicable0.1.A-ApplicationApplication for EnrollmentRequired01.B-Licensure State of Texas Professional LicensureRequired (submit for Region and position applying for)01.C-InsuranceInsurance Document Required01.D-DBAAssumed Name Certificate AttachmentIf applicable01.E-IncorporationCertificate of Incorporation AttachmentIf applicable01.F-LLCLLC Articles of Formation AttachmentIf applicable01.G-Partnership Partnership Agreement AttachmentIf applicable01.H-PartnersNames and addresses and for each partnerIf applicable01.I-HUB HUB Certification FormIf applicable FILE FOLDER 2: Required FormsElectronic File Name -Form NumberNAMEPURPOSEDocument Location74-176Vendor Direct Deposit FormDirect Deposit Authorization74-1761513Disclosure of Ownership and Control Interest StatementDocuments ownership and financial interest information15139007FFSInternal Control Structure QuestionnaireContractor's disclosure of internal controls. Instructions included.9007FFSAP-152Application for Texas Identification Number/Additional Mailing AddressApplication for Texas Identification NumberAP-152F-500-2970cCriminal or Abuse/Neglect History for Applicants, Employees, or Volunteers of DFPS Contractors and SubcontractorsUsed to disclose criminal and abuse/ neglect history for those who will be involved in direct delivery services with DFPS clients. Instructions included.2970cF-500-2971cRequest for Criminal History and DFPS History Check for Purchased Client Services Contractors Used to submit background checks for those who will be involved in direct delivery services with DFPS clients. Instructions included.2971c ................
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