Form 3681, Community Services Contract Application

Effective Date: 6/2015

Availability

PDF: 3681.pdf

Instructions

Updated: 6/2015

PURPOSE

Form 3681 is completed by individuals and organizations to apply for a contract to provide Department of Aging and Disability Services (DADS) Community Services.

Note: In addition to completing Form 3681, applicants who want to provide the following services must also complete the forms indicated.

  • Adult Foster Care or Residential Care: Form 3681-A, Community Services Contract Application – Addendum A
  • Adult Foster Care: Form 3681-B, Community Services Contract Application – Addendum B, Adult Foster Care Provider Questionnaire
  • Emergency Response Services: Form 3681-C, Community Services Contract Application – Addendum C, Emergency Response Services

INSTRUCTIONS FOR DADS STAFF

When to Prepare

Obtain a completed and signed Form 3681 for:

  • a new contract; or
  • an update to information on the form.

Form Retention

Retain Form 3681 and attachments in accordance with the records retention requirements in the Contract Administration Handbook.

APPLICANT'S INSTRUCTIONS FOR COMPLETING FORM 3681

Carefully read the following instructions. Errors and omissions will cause delays in processing Form 3681.

Section 1. Type of Application — Check the applicable box.

Section 2. Applicant's Legal Entity Information

Name of Legal Entity — Enter the full legal name of the entity, exactly as it was chartered, filed, registered or otherwise legally declared. If the applicant is an individual, enter the full legal name of the individual.

Doing Business As (d/b/a) — If applicable, enter the d/b/a(s) relevant to this contract.

Taxpayer Identification No. (EIN or SSN) — Enter the employer identification number (EIN) assigned to the legal entity by the Internal Revenue Service (IRS). If the legal entity is a sole proprietorship or individual who does not have an EIN, enter the owner’s or individual’s Social Security number (SSN).

Provider Identifier No. (NPI or API) — Enter the National Provider Identifier (NPI) number issued to the legal entity by the National Plan and Provider Enumeration System (NPPES) or the Atypical Provider Identifier (API) number assigned by DADS, whichever is applicable.

Name of Owner — If the legal entity is a sole proprietorship, enter the owner’s legal name. If the legal entity is not a sole proprietorship, leave blank.

Legal Entity Business Mailing Address — Self-explanatory.

Legal Entity Physical Address — Self-explanatory. If same as business mailing address, enter "same."

Location Where Service Delivery Records are Maintained — Indicate where service delivery records are maintained, if location is different from entity’s physical address. If address is the same, enter "same." For HCS and TxHmL service providers, this address must be in the contract waiver area(s) selected on Form 3691-A, Service Area Designation – HCS, TxHmL, CDS and TAS.

Contact Person — Enter the name of the person who can answer questions about the information furnished on the form.

Title or Relationship — Enter the contact person's title or relationship to the applicant's legal entity. Examples of title or relationship include CEO, partner, manager, executive director, authorized representative, spouse, etc.

Area Code and Telephone No. — Self-explanatory.

Physical Address — Self-explanatory.

Email Address — Self-explanatory.

Area Code and Fax No. — Self-explanatory.

Section 3. Applicant's Type of Legal Entity — Check the applicable box to indicate the legal entity’s type of business organization.

Important! Attach copies of the following certificates and documents applicable to the legal entity’s type of business organization.

Sole Proprietor

  • Copy of Social Security Card
  • Copy of Driver License
  • Certificate of Assumed Business Name as filed with the County

Corporation (for-profit and nonprofit)

  • Certificate of Formation as filed with Secretary of State
  • Certificate of Registration (if not formed in Texas, authority to transact business in Texas) as filed with Secretary of State
  • Articles of Incorporation
  • Bylaws, if applicable
  • Certificate of Assumed Business Name as filed with Secretary of State
  • Proof of IRS Tax ID Number (IRS Form CP-575 or LTR 147c)
  • Certificates of Amendments to original filing, if applicable

General Partnership

  • General Partnership Agreement
  • Certificate of Assumed Business Name as filed with Secretary of State
  • Copy of Social Security Card for each partner
  • Copy of Driver License for each partner
  • Proof of IRS Tax ID Number (IRS Form CP-575 or LTR 147c)
  • Any amendments to original General Partnership Agreement, if applicable.

Limited Partnership

  • Certificate of Formation as filed with Secretary of State
  • Limited Partnership Agreement
  • Certificate of Registration (if not formed in Texas, authority to transact business in Texas) as filed with Secretary of State
  • Certificate of Assumed Business Name as filed with Secretary of State
  • Certificates of Amendments to original filing, if applicable
  • Proof of IRS Tax ID Number (IRS Form CP-575 or LTR 147c)
  • Copy of Social Security Card for each partner
  • Copy of Driver License for each partner

Limited Liability Partnership

  • Applicable general or limited partnership documents (see above)
  • Evidence of filing Registration of a Limited Liability Partnership as filed with Secretary of State

Limited Liability Company

  • Certificate of Formation as filed with Secretary of State
  • Certificate of Registration (if not formed in Texas, authority to transact business in Texas) as filed with Secretary of State
  • Articles of Organization
  • Certificate of Assumed Business Name as filed with Secretary of State
  • Certificates of Amendments to original filing, if applicable
  • Proof of IRS Tax ID Number (IRS Form CP-575 or LTR 147c)

Section 4. Additional Legal Entity Information — Answer questions A through J as applicable to the legal entity identified in Section 2. If any question A through G is answered Yes, attach a full explanation of the circumstances.

Section 5. Existing Contracts with DADS — If applicable, provide the requested information for all contracts the applicant currently has with DADS. Copy this page and include as an attachment if additional entries are required.

Note: A document that lists all of the contracts the applicant currently has with DADS may be attached to the form in lieu of completing this section. For each contract listed, the document must include the following information:

  • applicant’s legal business name;
  • contract number;
  • taxpayer identification number;
  • business address; and
  • name, title and telephone number of contact person.

Section 6. Type of Contract You Wish to Obtain

Type of Contract — Click on the Community Services Contract Types link for a list of contract types. Enter the contract type abbreviation listed in the first column to indicate the type of contract you wish to obtain. Make separate entries for each contract type you wish to obtain.

Section 7. For Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Only

7a. Program and Billing Person

Program and Billing Contact Person — Provide the information requested for the individual who should be contacted about waiver program service issues and billing questions and issues.

7b. Program Manager

Provide the information requested for the individual who is responsible for managing and overseeing the direct provision of services to individuals enrolled in the DADS waiver program(s) and ensuring the legal entity's compliance with certification provisions and the terms and conditions of the provider agreement.

Note: This individual must attend the next scheduled provider applicant training and complete the certification exam. There are no exceptions to this requirement. Also, no substitutions for this individual during the application process are allowed. A written resume and three signed and verifiable professional references for this person must be submitted with this form.

Section 8. Licensure Information

8.a. For all DADS License Holders

Complete 8.a. if you wish to obtain a contract type that requires a DADS license. Otherwise, leave blank. Copy this page and include as an attachment if additional entries are required.

License No. – Enter the license number indicated on the license.

License Type – Enter "Facility" or "HCSSA," whichever is applicable.

Facility Category – Check the category of the license, if applicable.

HCSSA Category – Check the category or categories of the license, if applicable.

HCSSA Branch Office – Enter the location of any branch office that will provide services for the contract type(s) you wish to obtain (HCSSA only).

8b. For Adult Day Care (ADC) and Assisted Living (AL) License Holders Only

Legal Right to Occupy – Check Yes or No to indicate if the legal entity identified in Section 2 has a legal right to occupy the property in which the facility is located. Note: The applicant/legal entity may be required to submit proof of its legal right to occupy the property.

Real Property Ownership Information – Provide the information requested for the individual or business entity that owns the real property in which the facility is located.

Section 9. Applicant/Legal Entity Certification

The owner or an authorized representative of the legal entity must certify the information provided on the form, as well as all attachments, is true and complete. If the legal entity is not a sole proprietorship, the authorized representative must be named on a current Form 2031, Governing Authority Resolution – Business Organization, or Form 2031-G, Governing Authority Resolution – Governmental Entity, whichever is applicable to the legal entity, that is on file with DADS.

Documents

Community Service Contract Types

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