TX HHS Form 3455. Provider Staff Information

The TX HHS Form 3455, Provider Staff Information, is a crucial document that helps entities provide accurate and up-to-date information about their staff members who deliver Texas Health and Human Services Commission (HHSC) Independent Living Services Program services directly to consumers. This form must be completed for all personnel, including contract personnel and the director, but not support staff members.

The form requires entities to provide detailed information about each staff person, including their first name, last name, and any other names used. Entities must also ensure that the director on record with HHSC and appointed by the entity's legally authorized representative signs this form verifying the staff member's qualifications as documented in the HHSC ILS Standards for Providers.

To complete the form, entities should follow the instructions carefully, typing all information using a computer and obtaining required signatures. The form must be completed for new hires, significant changes in job duties or qualifications, terminations, and updates to existing information on file. Entities can submit the form by email or fax within 30 days of any of these events.

• The form is used to provide accurate and up-to-date information about staff members who deliver Texas Health and Human Services Commission (HHSC) Independent Living Services Program services directly to consumers.
• The form must be completed for all personnel, including contract personnel and the director, but not support staff members.