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, is a crucial document for entities seeking to contract with the Texas Health and Human Services Commission (HHSC) for waiver and community-based programs. This form helps ensure that all required forms and documents are submitted during the contract application process.

The checklist outlines the necessary information and documentation required from applicants, including legal entity name, doing business as (DBA), if applicable, and various forms such as Form 2031, Designation of Authorized Individual(s), and Form 3681, Community Services Contract Application. Additionally, applicants must submit a copy of their Employer Identification Number (EIN) verification and National Provider Identifier (NPI) confirmation email or letter.

This form should be used by contract applicants and HHSC staff to ensure a complete and correct application is submitted. Failure to submit all required forms and documents will delay the contract application process, which may result in denial of the application. Applicants are advised to carefully read the instructions before completing the form to avoid errors and omissions.