Number Name Purpose Form Location Disclosure and Consent to Release of information Release of Information regarding criminal history Regarding Criminal or or DFPS abuse and History For neglect history 2970C Applicants, Employees or Form D Volunteers of DFPS Contractors and Subcontractors Request for Criminal History Application for requesting 2971C and DFPS History Check criminal history and DFPS Form E abuse or neglect history Vendor Direct Deposit For vendor to receive 4108x Form F Authorization direct deposit Application for Texas Application for Identification identification number 4109x Number/Additional Mailing Form G Address Contracting Entity and List List the contracting entity, of Staff, Subcontractors, all service providers, and PCS-102ET and Volunteers Must requested provider Form H – include Medicaid Number information on this form. Internal Control Structure Contractor's disclosure of 9007FFS Questionnaire (ICSQ) for internal controls. Form I Fee for Service Contracts Instructions included Documents the 4736 Certificate of Insurance Contractor's Insurance Form J Coverage Documents the Evaluation & Treatment Contractor's Professional Form K 5627 Experience Summary Experience BIPP Application Checklist FORM M - STEP 1: Read the Evaluation & Treatment Open Enrollment for details of the terms and conditions of this contract. Focus on the sections that apply to BIPP Applicants. STEP 2: Organization of Electronic Submission of Application Applicant must organize its scanned and signed Application packet in the following order and format. Each flash drive or compact disc submission of the Application packet must include the following three (3) file folders with the respective listed documents included, and the documents must be in the following order, and numbered and labeled accordingly. Refer to Section 5,
Number Name Purpose Form Location 2970C Disclosure and Consent to Release of Information Regarding Criminal or History For Applicants, Employees or Volunteers of DFPS Contractors and Subcontractors Release of information regarding criminal history or DFPS abuse and neglect history Form D 2971C Request for Criminal History and DFPS History Check Application for requesting criminal history and DFPS abuse or neglect history Form E 4108x Vendor Direct Deposit Authorization For vendor to receive direct deposit Form F 4109x Application for Texas Identification Number/Additional Mailing Address Application for identification number Form G PCS-102ET Contracting Entity and List of Staff, Subcontractors, and Volunteers – Must include Medicaid Number List the contracting entity, all service providers, and requested provider information on this form. Form H 9007FFS Internal Control Structure Questionnaire (ICSQ) for Fee for Service Contracts Contractor's disclosure of internal controls. Instructions included Form I 4736 Certificate of Insurance Documents the Contractor's Insurance Coverage Form J 5627 Evaluation & Treatment Experience Summary Documents the Contractor's Professional Experience Form K FORM M - BIPP Application Checklist STEP 1: Read the Evaluation & Treatment Open Enrollment for details of the terms and conditions of this contract. Focus on the sections that apply to BIPP Applicants. STEP 2: Organization of Electronic Submission of Application Applicant must organize its scanned and signed Application packet in the following order and format. Each flash drive or compact disc submission of the Application packet must include the following three (3) file folders with the respective listed documents included, and the documents must be in the following order, and numbered and labeled accordingly. Refer to Section 5,
Application-Additional-Documents.docx