TX HHS Form 0009. Notice of Intent County Jail Reporting

The Texas Health and Human Services Commission (HHSC) requires county jails to submit a Notice of Intent to participate in reporting the confinement and release of individuals receiving healthcare coverage provided by HHSC. This form, TX HHS Form 0009, serves as a notice of intent for county jails to report this information.

This form collects essential information about the county jail, including its main facility name, mailing address, city, ZIP code, and county. Additionally, it requests details about any other facilities within the county that will be reporting confinement and release data. The primary contact person's information is also required, as they will receive instructions on how to complete, sign, and submit a Memorandum of Understanding (MOU) once their notice of intent is approved.

The purpose of this form is to inform HHSC of the county jail's intention to participate in reporting confinement and release data. By submitting this form, the county jail certifies that all provided information is true and accurate to the best of their knowledge. The electronic signature feature allows for a legally binding signature, indicating the county jail's commitment to comply with the requirements outlined by HHSC.