TX HHS Form 5873. Waiver and Community-based Programs and Services - Medicaid and CHIP Services Contract Application Packet Checklist

The TX HHS Form 5873, Waiver and Community-based Programs and Services - Medicaid and CHIP Services Contract Application Packet Checklist, helps ensure that all required forms and documents are submitted during the contract application process. This form is used by contract applicants and Texas Health and Human Services Commission (HHSC) staff to streamline the application process.

The form requires entities applying for a provisional contract with HHS to submit all necessary forms listed in Section 1, unless otherwise indicated. Key features of this form include the submission of required HHSC forms, which must be downloaded from the HHS Internet forms website or approved exceptions requested. Failure to submit all required forms and documents will delay the contract application process and may result in denial.

Applicants should carefully review the instructions before completing the form to avoid errors and omissions that can delay the application process. The following forms are typically submitted with this packet: Form 5873, Application Packet Checklist; Form 2031, Designation of Authorized Individual(s); and Form 3681, Community Services Contract Application.

• This form is used by contract applicants and HHSC staff to ensure all required forms and documents are submitted during the contract application process.
• Entities applying for a provisional contract with HHS must submit all necessary forms listed in Section 1, unless otherwise indicated.
• Required HHSC forms must be downloaded from the HHS Internet forms website or approved exceptions requested.