TX HHS Form 3681-B. Community Services Contract Application Addendum B - Adult Foster Care Provider Questionnaire

The TX HHS Form 3681-B, Community Services Contract Application Addendum B - Adult Foster Care Provider Questionnaire, is a crucial tool for adult foster care providers in Texas. This form helps solve the problem of providing essential information about the provider's identity, health status, and employment details to ensure compliance with state regulations.

The questionnaire requires the applicant to provide identifying information, including name, social security number, mailing address, and telephone number. It also asks about the applicant's health status, significant health problems or disabilities, and education level. Additionally, the form inquires about the applicant's employment details, such as employer, work telephone number, and annual earnings.

This form should be used by adult foster care providers seeking to contract with Texas Health and Human Services (HHS) for services related to adult foster care. The provider must complete this questionnaire fully before their application can be accepted. By providing the required information, the applicant demonstrates their commitment to meeting the necessary standards and regulations for operating an adult foster care program in Texas.