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

Form 5873 is an official checklist used in Texas during the application process for provisional contracts under Waiver and Community-based Programs and Services for Medicaid and CHIP. This document helps both applicants and Texas Health and Human Services Commission (HHSC) staff confirm that all required forms and supporting documents are included before a contract application is reviewed.

Purpose of Form 5873

The primary purpose of Form 5873 is to serve as a control and verification tool. It ensures that organizations applying to provide community-based services submit a complete and correct application packet. A properly completed checklist reduces delays, prevents rejections, and helps HHSC efficiently process contract applications.

This form is not a standalone application. Instead, it accompanies multiple other HHSC forms and business documents required during the contracting process.

Who Must Use This Form

Form 5873 must be used by:

• New applicants seeking a provisional HHSC contract for waiver or community-based services
• Organizations applying under Medicaid or CHIP service programs
• Business entities and governmental entities subject to HHSC contracting rules

HHSC staff also rely on this checklist when reviewing submitted application packets.

Legal and Regulatory Background

The use of Form 5873 is governed by Texas Administrative Code (TAC), Title 40, Part 1, Chapter 49. These regulations establish the requirements for obtaining provisional contracts for waiver and community-based programs. HHSC requires strict compliance with these rules to protect program integrity and ensure qualified providers deliver services.

Overview of Form Structure

Section 1 – Required Forms and Documents

This section lists all mandatory HHSC forms and documents that every applicant must submit, regardless of entity type. These include core application forms, ownership disclosures, cybersecurity acknowledgements, Medicaid enrollment documentation, and data security agreements.

Failure to include any item listed in this section commonly results in processing delays or application denial.

Section 2 – Criminal History Records Information

This section explains how criminal history information is handled. Applicants are instructed not to submit criminal history receipts at the initial stage. HHSC will request these records later if the application is deemed complete and eligible.

Section 3 – Required Business Documents by Legal Entity Type

This section varies based on the applicant’s legal structure. Each entity type must provide specific formation documents and personal identification for owners or partners.

• Sole proprietorships must provide personal identification and assumed name certificates.
• Corporations and nonprofits must submit formation documents, bylaws, and registration certificates.
• Partnerships must provide partnership agreements and partner identification.
• LLCs must include certificates of formation and registration.
• Governmental entities may need registration documents and identification for commissioners.

Section 4 – Required Documents by Program or Service Type

This section applies only to specific waiver programs or services. Requirements vary widely depending on the program, such as HCS, TxHmL, CLASS, DBMD, Hospice, or TAS.

Common requirements include licenses, training certificates, self-assessments, resumes of program managers, and professional reference letters.

Section 5 – Signature of Authorized Representative

The final section confirms that the application is signed by an owner or an authorized representative. If the entity is not a sole proprietorship, the signer must be officially designated on Form 2031 filed with HHSC.

When This Form Is Required

Form 5873 is required whenever an entity applies for a provisional contract with HHSC for waiver or community-based services. It is not optional and must be included with every initial application packet.

This form is not required for contract renewals unless specifically requested by HHSC.

Common Mistakes Applicants Make

• Submitting incomplete document sets listed in Section 1
• Using outdated versions of HHSC forms
• Failing to match legal entity names across documents
• Including criminal history receipts prematurely
• Missing required signatures or authorized representative designation

Practical Tips for Completing Form 5873

• Download all required forms directly from the HHSC website to ensure current versions.
• Review instructions for each form before completion.
• Verify consistency of legal entity information across all documents.
• Keep copies of everything submitted for your records.

Real-Life Application Scenarios

• A nonprofit organization applying to provide Texas Home Living (TxHmL) services uses Form 5873 to ensure all training certificates and references are included.
• An LLC seeking to become a Home and Community-based Services (HCS) provider uses the checklist to avoid missing licensing documents.
• A governmental entity applies for a community services contract and relies on Form 5873 to confirm compliance with HHSC documentation rules.

Documents Commonly Submitted with This Form

• Form 3681 – Community Services Contract Application
• Form 2031 or 2031-G – Authorized Individual Designation
• EIN verification from the IRS
• National Provider Identifier confirmation
• Applicable licenses and training certificates

Frequently Asked Questions

Is Form 5873 an application form?

No. It is a checklist that accompanies the full application packet.

Must all applicants submit every document listed?

Applicants must submit all documents applicable to their legal entity type and service program.

Can handwritten forms be submitted?

The application packet must be typed or legibly printed.

What happens if a document is missing?

HHSC may delay processing or deny the application.

Do I submit criminal history records with this form?

No. HHSC will request them later if needed.

Micro-FAQ

• Purpose: Confirms a complete HHSC contract application packet.
• Who files: Entities applying for waiver and community-based service contracts.
• Deadline: Submitted with the initial application packet.
• Attachments: Forms, licenses, identification, and business documents.
• Submitted to: Texas Health and Human Services Commission.

Related Forms

• Form 3681 – Community Services Contract Application
• Form 2031 – Designation of Authorized Individual
• Form 5871 – Disclosure of Ownership and Control
• Form 3691 – Service Area Designation

Form Details

• Form name: Contract Application Packet Checklist
• Form number: Form 5873
• Governing authority: Texas Health and Human Services Commission (HHSC)
• Region: Texas
• Revision date: September 2023