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 seeking to provide emergency response services in Texas. This form helps solve the problem of establishing a contractual agreement between the organization and the Texas Health and Human Services Commission (HHSC) for providing these essential services.

This addendum requires specific information from applicants, including legal entity details, service area and rate, and subcontractor information. Key features include the need to provide a name, doing business as (DBA), taxpayer identification number, national provider identifier, and base station physical address. The form also asks for proposed rates for emergency response services, both publicly funded and privately paid.

The TX HHS Form 3681-C should be used by organizations seeking to contract with HHSC for providing emergency response services in Texas. This includes entities that plan to serve specific counties or regions, as well as those that wish to provide services statewide. The form is designed to gather essential information about the applicant's legal entity, services offered, and rates charged, ensuring a comprehensive understanding of their capabilities and qualifications.