TX HHS Form 5830. Community-based Programs – Access and Eligibility Services Contract Application Packet Checklist. State Office Enrolled

The TX HHS Form 5830, Community-based Programs – Access and Eligibility Services Contract Application Packet Checklist, State Office Enrolled, is a crucial document for entities seeking to apply for a provisional contract with the Texas Health and Human Services Commission (HHSC). This form helps ensure that all required forms and documents are submitted during the application process, streamlining the contracting process.

This checklist requires entities to submit various forms and documents, including the Designation of Authorized Individual(s), Community Services Contract Application, Service Area Designation, Written Acknowledgement of Completion of Cybersecurity Training Program, Disclosure of Ownership and Control Statement, Verification of Employer Identification Number (EIN), National Provider Identifier (NPI) confirmation email or letter, Data Use Agreement, HHS Information Security and Privacy Initial Inquiry, and others. The form also specifies that entities must download required HHSC forms from the Texas Health and Human Services website.

The TX HHS Form 5830 is intended for contract applicants and HHSC staff to facilitate a smooth application process. It is essential to carefully read the instructions before completing any forms to avoid errors and omissions, which can delay the application process. Applicants should retain copies of all submitted forms and not send original business documents.