PEN Application and Contract, with instructions
NURSING FACILITY SERVICESAPPLICATION AND CONTRACTEnrollment #HHS0000014Identification InformationLegal Name of Applicant FORMTEXT ?????Doing Business As (DBA) NameIf different from Legal Name FORMTEXT ?????Attach a copy of Assumed Name CertificateVendor ID Number FORMTEXT ?????Federal ID Number – If different from Vendor ID FORMTEXT ?????Type of Applicant – Check “√” appropriate box(es) and attach documentation as indicated FORMCHECKBOX Individual/Sole Proprietor FORMCHECKBOX Limited Liability Company (LLC) FORMCHECKBOX CorporationType of Corporation: FORMCHECKBOX For Profit FORMCHECKBOX Non-ProfitState of Incorporation: FORMTEXT ?????Charter Number: FORMTEXT ?????Attach a copy of Certificate of Incorporation FORMCHECKBOX PartnershipType of Partnership: FORMCHECKBOX Limited FORMCHECKBOX GeneralAttach a copy of Partnership Agreement.If applicable, also attach a copy of the Signatory AssignmentContact InformationOffice Address (Street-Suite #) FORMTEXT ?????Office Address (City, State, Zip) FORMTEXT ?????Mailing Address (P.O. Box)If different from Office Address above FORMTEXT ?????Mailing Address (City, State, Zip)If different from Office Address above FORMTEXT ?????Phone- Primary Office FORMTEXT ?????Fax- Primary Office FORMTEXT ?????E-Mail- Primary Office FORMTEXT ?????Name-Primary Contact Person FORMTEXT ?????Title-Primary Contact Person FORMTEXT ?????Phone-Primary Contact Person FORMTEXT ?????Alternate Phone-Primary Contract Person FORMTEXT ?????E-Mail- Primary Contract Person FORMTEXT ?????Name- Person Authorized to Sign Contract FORMTEXT ?????Title- Person Authorized to Sign Contract FORMTEXT ?????Phone- Person Authorized to Sign Contract FORMTEXT ?????Alternate Phone- Person Authorized to Sign Contract FORMTEXT ?????E-Mail- Person Authorized to Sign Contract FORMTEXT ?????Name-Person Responsible for Billing FORMTEXT ?????Title- Person Responsible for Billing FORMTEXT ?????Phone- Person Responsible for Billing FORMTEXT ?????Alternate Phone- Person Responsible for Billing FORMTEXT ?????E-Mail- Person Responsible for Billing FORMTEXT ?????DFPS will send contract-related communications to the primary contact listed above. The Contractor must maintain and monitor at least one active e-mail address for the receipt of contract-related communications from DFPS. Services to Be ProvidedContractor must provide all Nursing Facility Services specified in Provider Enrollment #HHS0000014. Applicants must meet all DADS-licensed Nursing Facility and Medicaid Provider requirements. Indicate in the table below, if requirements are met:Is Applicant a DADS-licensed Nursing Facility? FORMCHECKBOX Yes FORMCHECKBOX NoDADS-license # FORMTEXT ????? Attach a copy of licenseIs Applicant a Medicaid Provider? FORMCHECKBOX Yes FORMCHECKBOX NoMedicaid Provider # FORMTEXT ????? Incorporation by ReferenceThe following documents are incorporated into the Contract for all purposes:Provider Enrollment #HHS0000014, including all addenda and attachmentsPurchase Order for Placement (POPS) Services Form 2202,Each Service Authorization Form 2311, prepared by DFPSOrder of PrecedenceThe Contractor will provide the services and deliverables described and required by all the documents listed in this Section. In the event of conflicts or inconsistencies between documents, such conflicts or inconsistencies will be resolved by reference to the documents in the following order of precedence:This PEN Application and Contract, 2280PEN, and any amendments thereto;Provider Enrollment #HHS0000014 and any amendments thereto; Each Service Authorization Form 2311 prepared by DFPS; and Purchase Order for Placement (POPS) Services Form 2202.CertificationI certify that the information provided in this application is, to the best of my knowledge, complete and accurate; that the named legal entity has authorized me, as its representative, to submit this application; and that the legal entity complies with all terms of this Provider Enrollment.By signing this PEN Application and Contract, applicant certifies that if a Texas address is shown as the address of the applicant, applicant qualifies as a Texas Resident Bidder as defined in Texas Administrative Code, Title 34, Part 1, Chapter 20.DFPS will post all official communication regarding this PEN on the HHSC Open Enrollments web page at . DFPS reserves the right to revise the PEN at any time. Contractors must comply with any changes, amendments, or clarifications posted to HHSC Open Enrollments web page. It is the responsibility of the Contractor to periodically check the HHSC Open Enrollments web page for updates to the procurement. The Contractor’s failure to periodically check the HHSC Open Enrollments web page will not release the Contractor from “addenda or additional information” resulting in additional costs to meet the requirements of the PEN.The undersigned representative agrees to all the terms and conditions specified in the Contract and by signing below agrees to execute the terms and conditions of the Contract upon receipt of a 2311 from the Department. Signature of Authorized RepresentativeDate FORMTEXT ?????Name of Authorized Representative (Printed) FORMTEXT ?????Title of Authorized Representative (Printed) FORMTEXT ?????Signature of Authorized DFPS RepresentativeDate FORMTEXT ?????Name of Authorized DFPS Representative (Printed) FORMTEXT ?????Title of Authorized DFPS Representative (Printed) FORMTEXT ?????Contract Information – For DFPS Use ONLYDFPS will complete the information below once Application is screened, reviewed, and accepted for contract.NoticesAny notice required or permitted under this contract by the Contractor to DFPS must be in writing and submitted to the DFPS address below:DFPS Office Address (Street;-Suite #; or P.O. Box) FORMTEXT ?????Contract TermContract Number (DFPS staff will complete) FORMTEXT ?????The initial contract period will begin on the effective date stated below, with the total contract term not to exceed sixty (60) months.Effective Date of Contract FORMTEXT ?????End Date of Contract FORMTEXT ????? ................
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