TX HHS Form 3681-C. Community Services Contract Application Addendum C - Emergency Response Services

The TX HHS Form 3681-C, Community Services Contract Application Addendum C - Emergency Response Services, is a crucial document for organizations providing emergency response services in Texas. This form helps solve the problem of ensuring that service providers have the necessary information to contract with the Health and Human Services Commission (HHSC) for emergency response services.

This addendum requires legal entities to provide specific information about their organization, including name, doing business as (DBA), taxpayer identification number, national provider identifier, base station physical address, and DADS region. Additionally, service providers must list the counties they wish to serve, propose a rate for their services, and disclose if they use subcontractors to provide emergency response services. The form also includes instructions for private pay rates and fees charged to customers.

The key features of this form include the required information about the legal entity and its services, as well as the conditions for using subcontractors. Service providers must complete the table provided in Section 3 if they use subcontractors to provide emergency response services. By filling out this form, organizations can demonstrate their compliance with HHSC requirements and move forward with contracting for emergency response services.

• The form is used by organizations providing emergency response services in Texas to contract with the Health and Human Services Commission (HHSC).
• The addendum requires specific information about the legal entity, its services, and subcontractors.
• The form helps ensure compliance with HHSC requirements for emergency response services.