TX HHS Form 5007. CMBHS Access Request and User Agreement

Form 5007, titled “CMBHS Access Request and User Agreement”, is a mandatory document for behavioral health providers in Texas who need access to the Clinical Management for Behavioral Health Services (CMBHS) system. This form is not a casual administrative sheet — it is a legal agreement between a provider organization and the Texas Health and Human Services System Agency. It determines who is allowed to access sensitive behavioral health data, under what conditions, and with what responsibilities.

Because CMBHS contains protected mental health information and core assessment tools (such as ANSA and CANS), Texas requires providers to formally register, verify their legal identity, and accept data-handling obligations. This form ensures that only authorized organizations gain access and that they meet the state’s requirements for secure reporting and documentation.

Purpose of Form 5007

The primary purpose of Form 5007 is to document:

• the provider organization’s legal identity,
• its eligibility to use CMBHS,
• the designated points of contact,
• its obligations regarding data reporting, security, and system use.

Completion of this form is required before a provider can create or update client profiles, perform ANSA or CANS assessments, or submit Medicaid-related behavioral health service data within CMBHS.

Explanation of Key Sections

1. Organization Information

This section verifies the legal name, physical and mailing addresses, county, and state. The name must match IRS, Comptroller, or Secretary of State records exactly. If the organization uses a DBA (“assumed name”), official documentation must be attached.

Common mistakes:

• Using the clinic’s brand name instead of the legal name in state filings.
• Entering an incomplete ZIP+4 code.
• Providing a PO Box where a physical site address is required.

2. Identification Numbers

Providers must supply one of the following identifiers:

• Texas Identification Number (TIN)
• Social Security Number (SSN)
• Federal Employer Identification Number (FEIN)
• National Provider Identifier (NPI)

This ensures that the entity submitting mental health service data is properly registered and recognized by federal and state systems.

3. Legal Status and Business Structure

Texas requires disclosure of the organization’s business type (nonprofit, LLC, partnership, etc.). Partnerships must list at least two partners’ SSN or TIN.

4. Historically Underutilized Business Certification

Providers indicate whether they are certified as a HUB. While optional, it helps Texas maintain equity records but does not affect system access.

5. Points of Contact

The form collects two essential contacts:

• Provider Point of Contact — handles operational matters
• MCO Point of Contact — liaison with the managed care organization

These individuals must be reachable and knowledgeable, as they receive security notices, system updates, and data submission feedback.

6. Section I – Definitions

This section explains key terminology, such as ANSA, CANS, Client Profile, and Utilization Management Guidelines. These are core tools used in Texas behavioral health programs and must be understood before accessing the system.

7. Section II – Purpose of the User Agreement

The User Agreement establishes legal responsibilities for secure submission of:

• client profiles,
• diagnosis records,
• CANS assessments,
• ANSA assessments.

It also clarifies when data must be submitted via the online interface and when Data Exchange may be used. Entities requesting Data Exchange access must undergo testing and comply with technical specifications provided by the System Agency.

8. Section III – System Agency Responsibilities

This section outlines what Texas HHS provides: system access, technical support, and documentation. It also confirms that the state has the authority to license the provider’s use of the CMBHS platform.

When This Form Is Required

• When a new behavioral health provider joins a Medicaid Managed Care network.
• When an existing organization expands services requiring ANSA/CANS submissions.
• When a provider reorganizes, merges, or changes its legal name.
• When requesting Data Exchange (automated data submission) access.

Situations Where You Do Not Need This Form

• If you are not providing Medicaid mental health services in Texas.
• If you do not perform ANSA/CANS assessments.
• If you are not submitting clinical client data to the state.

Real-World Examples

• Example 1: A new counseling center in Dallas begins providing youth services and needs CANS access. They must file Form 5007 before onboarding clients.
• Example 2: A clinic transitions from paper documentation to automated Data Exchange and submits Form 5007 to request technical specifications.
• Example 3: A provider acquires a second location; updated legal and contact information requires a new Form 5007 submission.
• Example 4: A behavioral health nonprofit rebrands and must update its legal name with Texas HHS.

Documents You May Need to Attach

• Proof of legal entity name (IRS, Comptroller, or Secretary of State filings)
• Assumed name certificate (if applicable)
• Partnership documentation (if listing partner SSNs/TINs)
• MCO agreement confirmation (optional but recommended)

Practical Tips for Completing the Form

• Match your legal name exactly as shown on state or IRS documents.
• Keep your Point of Contact emails active and monitored — system notifications are time-sensitive.
• Double-check identification numbers for accuracy; incorrect IDs delay access approval.
• If requesting Data Exchange access, prepare for mandatory testing before approval.

FAQ

• Who must file Form 5007? Medicaid behavioral health providers in Texas who need access to CMBHS.
• Can individual practitioners apply? Only if they operate as legally recognized entities with state filings.
• How long does approval take? Processing times vary but typically range from a few business days to two weeks.
• Is this form required for CANS/ANSA assessments? Yes. These assessments are submitted exclusively through CMBHS.
• What if my organization changes ownership? A new submission is required due to changed legal identity.
• Does this form grant billing privileges? No. It provides system access only.
• Can we use Data Exchange without testing? No. Completion of submission testing is mandatory.

Micro-FAQ (Short Answers)

• Purpose? To request access and agree to CMBHS usage rules.
• Who files? Texas Medicaid behavioral health providers.
• Needed for ANSA/CANS? Yes.
• Deadline? Before submitting any client data.
• Attachments? Legal name documents, assumed name certificates.
• Submitted to? Texas Health and Human Services (System Agency).
• Individual clinicians? Only if legally registered as entities.
• Data Exchange? Requires additional testing.
• Changes to provider info? Requires resubmission.
• Does it affect billing? No.

Related Forms

• Texas CANS Assessment Forms
• ANSA Assessment Forms
• Behavioral Health Provider Enrollment Applications
• Medicaid Managed Care Agreements (Texas)

Form Details

• Form Name: CMBHS Access Request and User Agreement
• Form Number: 5007
• Region: State of Texas
• Revision Date: August 2019