Texas Health and Human Services

This affidavit is a mandatory disclosure form required from anyone seeking temporary or permanent employment in a licensed child care facility, child-placing agency, or registered child-care home. Because these roles involve direct contact with children, the state requires applicants to formally confirm—under penalty of perjury—that they have no history of criminal conduct or child-related offenses that would compromise child safety.

Form 3034, the Children with Special Health Care Needs (CSHCN) Provider Assessment Form, is a key medical evaluation document used in Texas to determine whether a child or qualifying individual meets the medical eligibility criteria for the CSHCN Services Program. This form is always completed by a licensed health care provider—not the applicant or parent—and it must accompany Form 3031 during initial application or renewal.

Form 2962, “Verification of Liability Insurance,” is a document used by child care operations in Texas to confirm whether they maintain liability insurance as required under the Texas Human Resources Code (HRC) §§42.049 and 42.0495. This form is part of Texas’s broader framework for ensuring the safety of children in licensed, registered, and listed child care settings. It is submitted either during the application process or annually thereafter, depending on the type of operation.

Form 3016 is an official document used by the Texas Health and Human Services Commission (HHSC) to evaluate the professional background and suitability of individuals applying for a Child Care Administrator License or a Child Placing Agency Administrator License. This form must be completed by a person who has worked directly with the applicant—typically a supervisor, manager, or colleague who can provide authoritative insights into the applicant’s performance, leadership abilities, and professional conduct.

The Application for Program Benefits (Form 3029) is a comprehensive form designed to streamline access to essential health care services for low-income individuals and families in Texas.

The TX HHS Form 2807, Pending Enrollment of Youth Empowerment Services (YES) Waiver Services, is a crucial document for families seeking assistance with enrolling their child or youth in YES Waiver services. This form helps solve the problem of pending enrollment by providing a clear pathway for Medicaid application and subsequent waiver enrollment.

The TX HHS Form 2808, Youth Empowerment Services Waiver - Waiver Provider Selection, is a crucial document that helps solve the problem of selecting a provider for YES Waiver services. This form is typically completed by Comprehensive Service Providers (CSPs) or Wraparound Provider Organizations (WPOs) and submitted to the selected YES Waiver provider.

The TX HHS Form 2809, Youth Empowerment Services Waiver Verification of Freedom of Choice, is a crucial document that helps individuals make informed decisions about their healthcare services. This form is typically used by participants in the Medicaid-funded Youth Empowerment Services (YES) Waiver program to verify their freedom of choice in selecting a service provider.

The TX HHS Form 2810, Youth Empowerment Services (YES) Waiver - Participant Agreement, is a crucial document that helps solve the problem of ensuring participant understanding and consent for services provided through the YES Waiver program. This form is typically completed by Comprehensive Service Providers (CSPs) or Wraparound Provider Organizations (WPOs), as well as participants and their legally authorized representatives.

The TX HHS Form 2811: Youth Empowerment Services Waiver Letter of Withdrawal is a crucial document that helps solve the problem of individuals withdrawing from the inquiry list for the YES Waiver program. This form is typically used in situations where an individual or their legally authorized representative wishes to remove themselves from the interest list.