TX HHS Form 1091. First Dental Home Certification Application
Form 1091, also known as the First Dental Home (FDH) Certification Application, is a crucial document for dental providers participating in the Texas Health Steps program. This form ensures that eligible dentists are certified to provide preventive dental services for children in accordance with state regulations. Submission of this form is mandatory for new applicants seeking FDH certification, while already certified providers do not need to reapply.
Purpose and Overview of Form 1091
The primary purpose of Form 1091 is to officially register and certify dentists under the Texas Health Steps program as First Dental Home providers. This certification verifies that the dental provider has met the required training and continuing education standards, ensuring quality preventive dental care for children across Texas.
Section-by-Section Explanation
Dentist’s Name, Type of Practice, and Facility
This section collects the dentist’s full name, type of practice (individual or group), and type of facility. Accurate entry is critical for identification and program records.
- Common mistakes: Misspelling names or incorrect practice type can delay processing.
- Tip: Verify your NPI number before submission.
National Provider Identifier (NPI) Number
Enter your individual NPI and, if applicable, your facility’s NPI. The NPI ensures the provider is uniquely identified within federal and state health systems.
- Typical errors: Using an outdated NPI or omitting the facility NPI for FQHCs.
- Requirement: This field is mandatory for program verification.
Office Contact Information
Provide your office contact person, email address, physical office address, and phone number. The Texas Health Steps program uses this information to send confirmations and correspondence.
- Tip: Ensure email is active and regularly monitored to avoid missing notifications.
Training Date
Record the date you completed the required First Dental Home training. Only providers with verified training completion are eligible for certification.
Submission Instructions
Form 1091, along with a copy of the continuing education certificate, must be submitted by email or fax:
- Email: [email protected]
- Fax: 512-483-3979
Practical Recommendations
- Double-check all entries, particularly NPI numbers and training dates.
- Include a copy of the CE certificate to prevent delays.
- Use a reliable email address and monitor it for confirmation of receipt.
- Keep copies of submitted forms for your records.
Real-Life Examples
- A newly graduated dentist applying for FDH certification for the first time.
- An established pediatric dentist joining the Texas Health Steps program for preventive care services.
- A Federally Qualified Health Center (FQHC) dentist ensuring the facility and individual NPI numbers are correctly listed for compliance.
Required Documents
- Completed Form 1091
- Continuing education certificate verifying completion of required training
Legal and State Requirements
Form 1091 is governed by the Texas Health Steps program under the Texas Health and Human Services Commission (HHSC). Certification through this form is mandatory for all new dental providers wishing to deliver preventive dental services to children in Texas. Accurate completion ensures compliance with state regulations and eligibility for program participation.
FAQ
Who needs to submit Form 1091?
New dental providers seeking FDH certification under Texas Health Steps must submit this form.
Do current FDH-certified providers need to reapply?
No, if you are already certified, you do not need to submit a new application.
Can this form be submitted electronically?
Yes, submission can be done via email or fax as listed in the instructions.
What documents should be attached?
A copy of your continuing education certificate is required.
Who can fill out the form?
The dentist seeking certification or an authorized office representative may complete the form.
What are common errors to avoid?
- Incorrect or missing NPI numbers
- Omitting CE certificate
- Misspelled names or incorrect practice type
Micro-FAQ (Quick Answers)
- Purpose: Certify dentists as First Dental Home providers.
- Who files: New dental providers or authorized office personnel.
- Deadline: Submit promptly after completing required training.
- Attachments: CE certificate copy.
- Submitted to: HHSC via email or fax.
Related Forms
- Texas Health Steps Dental Provider Enrollment Form
- Continuing Education Verification Forms
- Other pediatric dental service forms under Texas Health Steps
Form Details
- Form Name: First Dental Home Certification Application
- Form Number: 1091
- Region: Texas
- Date of Issue: March 2022-E