TX HHS Form 5875. HCS Waiver Program Self-Assessment Certification

The TX HHS Form 5875, HCS Waiver Program Self-Assessment Certification, is a crucial document for organizations participating in the Home and Community-based Services (HCS) waiver program. This form helps ensure that providers are familiar with and committed to implementing the certification principles outlined in Texas Administrative Code 26, Part 1, section 565-565.37.

The form requires the legal entity name and doing business as (DBA) information to be provided by the authorized representative. The representative must review all HCS certification principles and indicate that the review is complete by signing the form below. This certification demonstrates the organization's commitment to complying with the programmatic requirements, staff member and service provider requirements, and other essential principles.

This self-assessment certification is typically used by organizations participating in the HCS waiver program to demonstrate their understanding of the certification principles and their commitment to implementing them. By signing this form, the authorized representative certifies that they are familiar with each of the TxHmL certification principles and that their organization will implement and comply with these principles.

• The form is used by organizations participating in the Home and Community-based Services (HCS) waiver program to demonstrate their understanding of the certification principles.
• The authorized representative must review all HCS certification principles and indicate that the review is complete by signing the form below.