TX HHS Form 5872. Certification of Pre-Application Orientation

The TX HHS Form 5872, Certification of Pre-Application Orientation, is a crucial document that helps solve the problem of ensuring providers have completed necessary orientation requirements for various services. This form is typically used in situations where providers are contracting to offer services such as Community Living Assistance and Support Services (CLASS), Day Activity and Health Services (DAHS), or Primary Home Care/Family Care/Community Attendant Services (PHC/FC/CAS). The authorized representative of the entity must fill out this form, certifying that they have read the corresponding pre-application orientation guide.

The form requires the legal name of the entity, type or print, as well as the signature and date of the authorized representative. This certification serves as a condition for contracting with Texas Health and Human Services (HHS) to provide these services. By completing this form, providers demonstrate their understanding of the necessary procedures and responsibilities associated with each service.

Key features of this form include:

• The requirement to read the corresponding pre-application orientation guide for the specific service being contracted
• The need for certification by an authorized representative of the entity
• The provision of legal name, type or print, and signature of the authorized representative
• The date of certification