TX HHS Form 5871. Disclosure of Ownership and Control Statement

Form 5871, Section 9, is a legally binding certification document used by entities seeking to enroll in the Texas Medicaid program or to secure a community services contract with the Texas Health and Human Services Commission (HHSC). This section is not a standalone form but a critical, concluding part of a larger application packet. Its primary function is to formalize the applicant's attestation to the truthfulness and completeness of the information provided throughout the entire application process.

Purpose and Use of the Form

The core purpose of this certification is to ensure integrity and accountability in the application process for government-funded health and community services. By signing this section, the entity makes a sworn statement that all submitted information is accurate. This serves as a safeguard for HHSC, protecting public funds from fraud and ensuring that only qualified and compliant entities are permitted to provide services to vulnerable populations in Texas. It is a mandatory step for enrollment or contracting.

Who Uses This Form?

This form is completed by "disclosing entities," which is a broad term encompassing various organizations. Typical users include:

• Healthcare providers (e.g., doctors, clinics, home health agencies, nursing facilities).
• Community service organizations (e.g., agencies providing disability support, early childhood intervention, mental health services).
• Any other entity applying to become a vendor or contractor with the Texas HHSC.

The individual signing the form must be a person with significant authority within the organization, specifically the owner or an authorized representative who has the legal capacity to bind the entity.

Key Sections and Data Requirements

Although brief, Section 9 contains several critical components and legal commitments:

• Certification Statement: A declaration that all information in the form and any attachments is true and complete.
• Consequences of Falsification: An explicit acknowledgment that providing false information is sufficient cause for HHSC to:
  • Deny the entity's application to enroll in Texas Medicaid.
  • Deny the entity's community services contract application.
  • Terminate the entity's existing contract, if one is already in place.
• Ongoing Duty to Update: A commitment to keep the provided information current as a condition of participation in HHSC programs. The signee agrees to submit updated information in accordance with the specific regulations outlined in the Texas Administrative Code.
• Signature Block: This area requires:
  • The physical or digital signature of the Owner or Authorized Representative.
  • The date the form is signed.
  • The typed or printed name of the signatory.
  • The official title of the signatory within the organization.

Legal and Regulatory Requirements

The certification carries significant legal weight. It is governed by the rules established in the Texas Administrative Code, Title 26, Part 1, Chapter 52 (relating to Contracting for Community Services). The requirement to maintain and submit updated information is not a mere formality; it is a continuous condition of participation. Failure to adhere to this can result in the same severe consequences as providing false information at the application stage, including contract termination and potential legal liability.

Typical Application Scenarios

This form is essential in the following situations:

• Initial Application: When a new healthcare provider or community service organization applies for the first time to become a Texas Medicaid provider or an HHSC contractor.
• Contract Renewal or Revalidation: During periodic re-screening processes that HHSC requires for existing contractors to maintain their status.
• Ownership Change: When there is a change in ownership or control of an already-enrolled entity, triggering a need to re-disclose and re-certify information.

Form Name: Form 5871, Section 9. Disclosing Entity’s Certification
Form Number: 5871
Governing Organization: Texas Health and Human Services Commission (HHSC)
Revision Date: 08-2024