Attachment A-3 - Texas Health and Human Services



Service Delivery Staff QualificationsEach direct service provider must meet the Minimum Qualifications described in Provider Enrollment (PEN) §2.6. Use the link below, to access the Contracting Entity and List of Staff, Form PCS-102SUD and complete all information for each person who will provide services under any contract award pursuant to this PEN. Submit the completed form with this Application. The form is also available at: you have indicated the use of subcontractors on PCS-102SUD, the following must be submitted for review:Subcontracting policies and procedures, and a copy of the subcontract to be used in the delivery of services being contracted and that are in compliance with procurement, monitoring and processing back ground check requirements. DFPS will utilize the Subcontracting Review & Acceptance Form, PCS-107 to document acceptance of these policies and procedures and the subcontract document. The Contractor is encouraged to use Form PCS-107, located at: Service Delivery Area DetailDFPS Regions are served on a county basis and the Applicant may select the available counties within each Region. Applicant selected the Region to serve in Form 2280PEN Application and Contract, Number 6. Now Applicant must select the counties within each of these Region(s) where services will be provided.Select Counties and Application RequirementTo select counties to be served, follow these steps: Open Form A-3a Service Delivery Area document for a list of the Region(s) that will be served. Select the counties to be served from the list of available counties within each Region. Note: All counties within a Region may not be currently available for enrollment. Only counties in bold and with a “?” in front of the county name are available for enrollment.Return Form A-3a Service Delivery Area detail page for the service region(s) with your completed Application packetContractor will be required to provide services within each county selected.OfficesWill you, your staff, or subcontractors be delivering services from satellite office sites other than the location listed on Form 2280PEN, Application and Contract, #3? FORMCHECKBOX Yes - (if yes, be sure to complete question 4.4 below) FORMCHECKBOX NoIndicate locations that you, your staff, or subcontractors are willing to provide services: FORMCHECKBOX In-Office FORMCHECKBOX Out of OfficePrimary OfficePrimary office is designated on Form 2280PEN, Application and Contract, #3, Contact Information. Complete table below providing a schedule for the days and times routinely available to provide services at the primary office location. These represent only routine days and times. Applicant will be expected to adjust schedule to accommodate the needs of DFPS clients.DAYHOURSFromToFromToExample7 AMNoon2 PM7 PM FORMCHECKBOX Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Sunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Satellite Office(s)Designate any satellite office(s) by completing the table and providing a schedule indicating days and times routinely available to provide services at each satellite office location. These represent only routine days and times. Applicant is expected to adjust schedule to accommodate the needs of DFPS clients. Use additional copies of this section, as necessary, to provide complete information.Service Delivery Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Phone FORMTEXT ?????Fax FORMTEXT ?????Contact Person FORMTEXT ?????E-mail FORMTEXT ?????DAYHOURSFromToFromToExample7 AMNoon2 PM7 PM FORMCHECKBOX Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Sunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Service Delivery Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Phone FORMTEXT ?????Fax FORMTEXT ?????Contact Person FORMTEXT ?????E-mail FORMTEXT ?????DAYHOURSFromToFromTo FORMCHECKBOX Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Sunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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