Completing Form 2021
Licensing Application

 

DADS Presentation
Completing Form 2021 Licensing Application

Home and Community Support Services Agencies

 

Form 2021

Overview

Purpose

The purpose of this presentation is to provide information about the Form 2021 Licensing Application and the rules affecting the application located in the Texas Administrative Code (TAC), Title 40, Part 1, Chapter 97 Subchapter B  licensing standards as it relates to the Home and Community Support Services Agencies (HCSSA).

 

This information will equip the participant  to understand the licensing process and application requirements.

 

 

 

 

 

 

 

 

Where To Find Information:

Application- http://www.dads.state.tx.us/forms/2021/

 

It will be helpful to print the application Form 2021 so it may be reviewed throughout this course.

 

Subchapter B - http//wwwdadsstateus/handbooks/lshcssa/

 

Who Should Fill Out Form 2021

Those persons providing Home Health, Hospice or Personal Assistance Services (PAS) for pay or other considerations in a client's residence, an independent living environment or another appropriate location should submit this application.

Complete this form for all initial parent, renewal and Change of Ownership (CHOW) applications.

 

 

 

 

 

 

 

 

 

 

 

 

 

An applicant may receive an application packet from DADS or download one from the DADS website. http://www.dads.state.tx.us/

Filling out a form

Objectives

 

In this course you will review the:

  • Texas Administrative Code (TAC), Title 40, Part 1, Chapter 97 Subchapter B; and
  • Licensing Form 2021.

 

 

Healthcare professionals

Organization

 

This presention:

  • is designed to provide only general information about the licensing application requirements. It remains the full responsibility of each applicant to complete the application in its entirety with accurate information;
  • follows Form 2021 which is divided into sections that require the applicant to fill out specific information; and
  • includes information from Title 40, Part 1, Chapter 97 Subchapter B to ensure the participant has all the required information to complete Form 2021.

 

The particpant should scroll over the images or underlined words for more information.

 

National Provider Identification Number

 

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Prior to submitting your Application Form 2021 you will need your National  Provider Identification number.    

 

The National Provider Identification (NPI) number is the standard unique health identifier for health care providers and is assigned by the National Plan and Provider Enumeration System (NPPES). To obtain an NPI, you may apply online at https://NPPES.cms.hhs.gov.

 

NOTE:  Once you have the NPI you may submit your application. Traffic light green

 

 

 

 

 

 

Presurvey Conference CBT

 

To avoid delays in the application process, the applicant should ensure that the appropriate individuals have completed the presurvey computer-based training (CBT) before submission of Form 2021. The applicant must print documentation of completion for each of the required individuals and submit proof of completion with the application.

 

According to §97.13, the presurvey conference CBT must be completed by the individuals below:

  • the designated administrator and an alternate of a personal assistance agency; or
  • the designated administrator, alternate administrator, supervising nurse and alternate supervising nurse of all other types of agencies.

 

The presurvey conference CBT is on the DADS website at http://www.dads.state.tx.us/providers/hcssa/cbt.

 

 

Individuals sitting at computer  

Scroll over the image for suggestions on taking CBT's.

Form 2021 Sections

The application is divided up into 14 sections. You may click the links below for individual sections.

 

Section 1-Type of Application

Section 8-Contracts with State Agencies

Section 2-Licensing Fees

Section 9-Categories of Service

Section 3-Legal Entity Name

Section 10-Renewals or CHOWS only

Section 4-Doing Business As (DBA) Name

Section 11-Geographic Service Areas

Section 5-Address

Section 12-Ownership Disclosure

Section 6-Management Information

Section 13-Adverse Legal History

Section 7-Accreditation Status

Section 14-Affidavits

 

 

Filling out an application

Begin Completing Form 2021

Some Do's and Don'ts:

Do type or print all information so that it is legible.

Don't use pencil or white out correctional fluid.

Do report additional information within a section by copying and completing that section for each additional entry.

Do submit all required supporting documentation, including the required fee.

Do keep a copy of your completed application with the attachments and a copy of your check for your records.

Do complete and furnish all documents and information that DADS requests in accordance with instructions provided with the application packet. 

Don't submit documents without being notarized.

Don't forget to complete all applicable sections of the application.

 

 

 

 

 

Picture of form 2021

Section 1 Type of Application

 

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Use the application form to apply for an Initial, Change of 50% or more of stock/Ownership (CHOW), Renewal, and Relocation.

The application form must also be used to update DADS about changes that affect your agency such as:

•management personnel;

•operating hours;

•telephone and fax numbers;

•agency service area (expanding or reducing);

•category(ies) of service(s) (adding or deleting);

•ownership interests and/or stock transfer of 49% or less;

•agency name (legal entity name and/or DBA); and

•chief financial officer (CFO).

Picture of section one of form 2021

Types of Application

 

The next section of slides explain each of the application types in section one of Form 2021. Review each type or proceed to the type of application pertinent to your circumstances. Please read the section and its corresponding rules located both here and in the TAC Chapter 97 Subchapter Part B.

 

Place a check mark on Form 2021 beside the type of application, you are seeking a license for, in section one.

 

Arrow pointing down

Picture of section one of form 2021

§97.11 Initial Licensure

 

Important facts about initial licensure from §97.11

  • A first-time application for a license is an application for an initial license.
  • An application for a license when there is a CHOW is an application for an initial license.
  • A separate license is required for each place of business as defined in §97.2.
  • An agency's place of business must be located in and have an address in Texas.
  • An applicant must be at least 18 years of age.

 

Symbol for criteria

Scroll over the image for more information.

Outline of Texas

 Before issuing a license, DADS considers the background including criminal history and qualifications of:

  • the applicant;
  • a controlling person of the applicant;
  • a person with a disclosable interest;
  • an affiliate of the applicant;
  • the administrator;
  • the alternate administrator; and
  • the CFO.

 

§97.11 Initial Licensure

 

Symbol for criteria

Initial licensure applicants must meet certain criteria.

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The applicant must not: have an unsatisfied final judgment in any state or other jurisdiction; be in default on a guaranteed student loan (Education Code, §57.491); or be delinquent on child support obligations (Family Code, Chapter 232). 

 

Right pointing arrow In the last two years, the applicant must not have a history in any state or other jurisdiction of any of the following: an unresolved federal or state tax lien; an eviction involving any property or space used as an inpatient hospice agency; or an unresolved final Medicare or Medicaid audit exception.

 

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In the last 12 months, the applicant must not have a history in any state or other jurisdiction of any of the following: denial, suspension, or revocation of an agency license or a license for a health care facility; surrender a license before expiration or allowance of a license to expire instead of the licensing authority proceeding with enforcement action; a Medicaid or Medicare sanction or penalty relating to the operation of an agency or a health care facility; operation of an agency that has been decertified in any state under Medicare or Medicaid; or debarment, exclusion, or involuntary cancellation.

§97.13 Initial Licensure

 

Application procedures for certification

 

When an agency requests the initial license application including certification, the applicant completes and submits a CMS-855A enrollment application and all supporting documentation to its fee-for-service contractor.

 

The fee-for-service contractor reviews the application and makes a recommendation for approval or denial to DADS, with a copy to the Centers for Medicaid and Medicare Services (CMS) Regional Office.

 

The applicant may have an approved accreditation organization conduct a certification survey. Currently DADS must complete all Tier I, II, and III before conducting certification surveys per Provider Letter 2015-09.

 

If CMS certifies an agency to participate in the Medicare program, DADS sends a notice to the agency that the category of Licensed and Certified (L&C) has been added to the license.

 

If CMS denies certification to an applicant or if the applicant withdraws the application for participation in the Medicare program, the agency may retain the category of licensed only. For more information click here §97.13

 

Test Your Knowledge

 Directions: Answer each question. If needed you may review previous slides.

§97.17 Renewal

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Graphic with the words time for renewal

Factors that affect a renewal licensure from §97.17

 

 

In order to continue providing services to clients, an agency must renew its license and have a successful survey or be satisfactorily accredited.

 

An agency whose license expires must close and apply for an initial license. An agency license is valid for two years.

 

If an agency provides inaccurate or false statements or withholds information from the renewal application and/or attachments to the application, DADS may assess the penalties against the agency that apply in §97.13.

 

For each licensure period, an agency must provide services to at least one client. DADS does not require an agency to admit a client under each category of service authorized under the license as a condition for renewal of the license.

§97.17 Renewal

 

DADS sends out a reminder of expiration.

Downward arrow

Timeline graphic for a renewal license. See text to the left.

 

Renewal licensure process

 

Renewal applications must be submitted before the expiration date. DADS sends a reminder at least 120 days before the expiration.

 

If an agency does not receive the reminder from DADS at least 90 days before the expiration date of a license, the agency must notify DADS and submit a written request for a renewal application.

 

An agency must submit to DADS a complete and correct renewal application and the required license fee specified in §97.3. The packet must be postmarked no later than the 45th day before the expiration date of the license.

 

If an agency submits a renewal application that is postmarked later than the 45th day before the expiration date of a license, but no later than the expiration date of the license, DADS assesses the late fee set out in §97.3(b).

 

Test Your Knowledge

 

 Directions: Complete the following questions below by clicking the best answer. At the end of the questions please click on the button to check your answers. If you need more information, refer to §97.17.

 

§97.17 Renewal

Factors affecting a renewal application

 

The agency must cease operation on the date the license expires if DADS does not receive a renewal application postmarked before the expiration date.

 

If at the time an agency submits a timely renewal application, and an action to revoke, suspend, or deny renewal of the license is pending, the agency may continue to operate. The license is valid until the agency has had an opportunity for a formal hearing as described in §97.601.

 

DADS notifies an agency, in writing, if an application does not include all documents, information, or the license fee. An agency must submit the missing documents, information, or fee to DADS postmarked no later than 30 days after the date of the notice or DADS considers the renewal application incomplete and denies the application.

 

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§97.17 Renewal

Salute of American flag

 

Special military considerations

This applies to a license holder who is an individual or a partnership comprised of individuals, all of whom are or were on active duty with the armed forces of the United States of America serving outside the state of Texas.

 

An individual having power of attorney from the license holder or other authority to act on behalf of the license holder may request renewal of the license.

 

An agency may request a renewal application before or after the expiration of the license.

 

A copy of the official orders or other official military documentation showing that the license holder is or was on active military duty serving outside the state of Texas must be filed with DADS along with the renewal application and a copy of the power of attorney from the license holder or other authority to act on behalf of the license holder must be filed with DADS along with the renewal application.

 

A license holder is not authorized to operate the agency for which the license was obtained after the expiration of the license unless and until the license holder actually renews the license.

 

§97.23 Change of Ownership

 

People holding up the letters to spell change

Important factors affecting a CHOW

 

A CHOW occurs when there is a change of 50% or more in the ownership (interest and/or stock) a change in the Employer Identification Number (EIN).

 

A change of ownership does not apply if an agency  is amending its official documents to revise its name.

 

A change of ownership for a parent agency is a change of ownership for the parent agency's branch office or alternate delivery site and requires the submission of an initial application and license fee for the branch office or alternate delivery site.  

 

Click here §97.23 for more information.

 

§97.25 Change of Ownership

Important factors affecting a CHOW

An applicant must notify DADS at least 60 days before the effective date of the CHOW.

 

A prospective new owner must submit a postmarked, complete and correct application packet for a license and the appropriate license fee at least 30 days before the date of sale or other transfer of ownership, and before the expiration date of the license.

 

If an applicant submits a timely and complete application packet and license fee and meets all criteria for a license, DADS issues the applicant a license effective on the date of the transfer of ownership.

§97.25 Change of Ownership

 

 

Time factors when submitting CHOW application packets

 

If a complete and correct application packet and license fee to DADS is postmarked less than 30 days before the anticipated date of sale is submitted the applicant is required to pay the late fee set out in §97.3.

 

 

Under new ownership sign

If a complete and correct application packet and license fee to DADS is received by the date of sale, the applicant must prove to DADS' satisfaction that the health and safety of the agency's clients requires an emergency CHOW.

 

If an incomplete application packet and license fee is submitted to DADS, it must contain  a letter explaining the circumstances that prevented its completion. The letter must be postmarked at least 30 days before the anticipated date of sale. DADS must accept the explanation and the applicant must submit the missing information to DADS within 30 days after the date of the letter.

 

Test Your Knowledge

 Directions: Using the information you just read, answer the True/False questions. Please click on the button at the end to check your answers.

§97.213 Relocation

 

Factors affecting a relocation

 

An agency must not transfer a license from one location to another without prior notice to DADS. The agency must submit written notice to DADS to report a change in physical location at least 30 days before the intended relocation according to §97.213.

If an agency reports a change in physical location, the agency must pay a fee and may be subject to a late fee, as described in §97.208.

 

DADS will send the agency a Notification of Change reflecting the new location. The agency must post the Notification of Change beside its license in accordance with §97.211.

 

An agency is exempt from the requirements when reporting a temporary relocation that results from the effects of an emergency or disaster, as specified in §97.256.

 

 

 

Moving Box  

Test Your Knowledge

 Directions: Answer the multiple choice question with the best answer. If needed you may refer back to the previous slide. Please click on the button to check your answer.

§97.218 Change in Organization

 

 

 

Factors affecting a change in management

 

If a change occurs in the following management personnel, an agency must submit written notice to DADS no later than seven days after the date of a change in an: administrator, alternate administrator, chief financial officer or controlling person, as defined in §97.2.

 

When an agency has a change in management personnel, the agency must pay a fee and may be subject to a late fee, as described in §97.208.  An agency is not required to pay a fee to report a change in alternate administrator, but the agency must pay a late fee, as described in §97.208, if the agency does not report the change within the time frame required.

 

DADS will use the postmark to determine whether or not to assess a late fee.

 

A change in the management personnel requires DADS evaluation and approval. DADS notifies an agency if the information the agency provides does not reflect that a person meets the required qualifications per §97.218 .

 

Updates

DADS requires certain updates be reported using Form 2021. Scroll over the TAC to learn about more information.

Please review these individual sections if they apply located at http://www.dads.state.tx.us/handbooks/lshcssa/.

 Rule

 Application Change

 DADS Form 2021 Requirentes

 

§97.213

 

 

Agency Relocation (physical address)

 

 

Page 1 (Sections 1, 3, 4, 5a and  5b) and Page 20

 

 

§97.214

 

 

Mailing Address (if different from physical address)

 

Page 1 (Sections 1, 3 and 5b) and Page 20

 

 

§97.214

 

 

Agency Contact Information (telephone number) or Operating Hours

 

 

Page 1 (Sections 1, 3, 5 and 6) and Page 20

 

 

§97.215

 

 

Agency Name (Doing Business As (DBA), not change of ownership)

 

 

Page 1 (Sections 1, 3, 4 and 5) and Page 20

 

 

§97.215

 

Name of Owner (Legal Entity) (name change only, not change of ownership)

 

Page 1 (Sections 1, 3, and 5) and Page 20

 

Additional update information on the next slide.

Updates

DADS requires certain updates be reported using Form 2021. Click on the TAC for more information.

Please review these individual sections if they apply located at http://www.dads.state.tx.us/handbooks/lshcssa/.

Rule

Application Change

DADS Form 2021 Requirements

§97.218

 

Agency Organization (management – administrator or chief financial officer)

 

Page 1 (Sections 1, 3, 4, 5 and 6) and Page 20

 

§97.218

 

Agency Organization (management – administrator or chief financial officer)

 

Page 1 (Sections 1, 3, 4, 5 and 6), Page 2 (Section 10a), Page 5 (Section 12a, 12b and new ownership information), Page 9 (Section 12b(iv) if applicable) and Page 20

 

§97.218

 

Agency Organization (management – alternate administrator)

 

Page 1 (Sections 1, 3, 4, 5 and 6) and Page 20

 

§97.219

 

Category of Service (adding or deleting)

 

Page 1 (Sections 1, 3, 4, and 5), Page 2 (Section 9) and Page 20

 

§97.220

 

Service Area (expanding or reducing)

 

Page 1 (Sections 1, 3, 4 and 5), Page 3 (Section 11), Page 4 and Page 20

 

Test Your Knowledge

  

Section 2 Licensing Fees

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This is section 2 on Form 2021. It informs the applicant of the licensing fees for the types of license for which you are applying. The Health and Safety Code Chapter 142, Section 142.010, authorizes the Texas Department of Aging and Disability Services (DADS) to set home and community support services agency licensing fees. Licensing fees for an initial, renewal or CHOW are $1750.00. Remember that an application is not considered complete until the applicant pays the full licensing fee. Fees paid to DADS are not refundable.

Licensing fees are set forth in §97.3 .

Other fees are listed below.

 

Update Change

Fee

 Update Change 

Fee

 

Update Change

 

Fee

Agency Contact Information (telephone number) or Operating Hours

 

$0

Mailing Address

(if different from physical address)

$0

 

Agency Relocation (physical address)

 

$30

 

Agency Organization (management – administrator or chief financial officer)

 

$30

Agency Name (Doing Business As (DBA), not change of ownership)

 

$30

 

Name of Owner (Legal Entity) (name change only, not change of ownership)

 

$30

 

Category of Service (adding or deleting)

$30

 

Agency Organization (management – alternate administrator)

 

$0

 

Service Area (expanding or reducing)

 

$30

 

Note: DADS collects other fees related to changes when an untimely Form 2021 is received. Please see §97.208 for information on late fees.

 

 

Test Your Knowledge

  

Section 3 Business Information

Fill out the correct information for each box on the application.

Ensure the legal business entity shown in Section 3 matches the name on the tax documents, articles of incorporation or articles of organization, Submit a copy of the documentation from the NPI office and documentation from the IRS of the tax ID number.

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 Section 3 of Form 2021

A legal entity could be a corporation, limited partnership, general partnership, sole proprietor, limited liability company, city, county, state or federal government authority or hospital district/authority or a trust, living trust, estate.

The National Provider Identification (NPI) is the standard unique health identifier for health care providers and is assigned by the National Plan and Provider Enumeration System (NPPES).

 

Section 4 and 5 Name and Address

Fill in the blanks on the application

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Name the Agency will be DBA

Ensure Item 4 indicates the name the agency that your agency will be DBA.

This is the same name as the legal entity name unless otherwise filed with the Secretary of State as an assumed name.

 

Section Five 5(a) requires you to document the physical location adress, which is the actual location of the agency (for example, where all the original files are kept and services are delivered and administered). The mailing adress should be documented on line 5(b) and it is where the agency receives its correspondance.

Fill in the physical address and mailing address in this section of the application. Please include city, county and zip code. The mailing address is where the agency receives its correspondence.

 

 

Section 6 Management Information

Fill out all the required information. Do not leave any blanks on the form. All agencies must have an administrator and an alternate administrator.The supervising nurse and alternate supervising nurse are required for agencies requesting Licensed Home Health, Licensed and Certified Home Health Services, and Hospice categories. Those agencies requesting only the category of Personal Assistance Services do not require a supervising nurse or alternate supervising nurse.

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Section 6 of Form 2021

Remember PAS agencies must designate an administrator and an alternate administrator and all other types of agencies must designate an administrator, alternate administrator, supervising nurse and alternate supervising nurse.

 

 

Section 7 Accreditation Status

DADS recognizes three accrediting organization and the links to their websites are listed below. This section of the application informs DADS of the status of your accreditation.  Please check yes or no on the application for each question.

 

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Section 7 of Form 2021

Click on these linksStamp with the word accredited to view accreditation agencies:

•http://www.jointcommission.org

•http://www.chapinc.org/

•http://www.achc.org/

 

Section 8 Contracts with State Agencies

Follow the directions on the application for each blank. Scroll over the image below for more information.

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Section 8 of Form 2021

Pen with the word contract Click on these links for more information on these programs:

Primary Home Care

Community Based Alternatives

Medically Dependent Children Program

Deaf Blind with Multiple Disabilities

Community Living Assistance and Support Services

 

Section 9 Categories of Service

Each of these categories are defined and reviewed during the presurvey conference CBT. If you have questions please review the CBT. Complete this section on the application by checking the category(ies) of service you offer. Scroll over the image below for more information.

 

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Section 9 of Form 2021

Each of these categories of service are explained in the required CBT Presurvey Conference.Stack of books

 

Test Your Knowledge

 DIrections: Using the information from the previous slides, select the best answers. Please click on the button at the end to check your answers.

Section 10 Renewal or CHOW Only

Fill out the blanks in this section of the application completely. Scroll over the image below for more information.

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Section 10 of Form 2021

Census Data for Renewal (complete (i) through (iv)) and Change of Ownership (complete (iii) and (iv) only)

 

(i)Total number of unduplicated clients served in the last licensure period ________________

 

(ii)Number of unduplicated clients served in the last licensure period by categories of service:

L&CHHS_____   L&CHHS w/home dialysis _____ LHHS______ LHHS w/home dialysis _____ PAS _____ Hospice______

 

(iii)Total current unduplicated client census ______________

 

(iv)Current unduplicated client census by category of service

L&CHHS_____   L&CHHS w/home dialysis _____ LHHS______ LHHS w/home dialysis _____ PAS _____ Hospice______

 

The information provided in (i) through (iv) should not include the clients served by branch offices or alternate delivery sites. Note: The sum of (ii) must equal (i) and the sum of (iv) must equal (iii).

 

Texas Star

Section 11 Geographic Service Area

 

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This section is divided up into regions. Please check the boxes for each of counties you serve.

•REGION 1 – Lubbock

•REGION 2 – Abilene

•REGION 3 – Box with a check markMetroplex

•REGION 4 – Tyler

•REGION 5 – Beaumont

•REGION 6 – Houston

•REGION 7 – Austin

•REGION 8 – San Antonio

•REGION 9 – Abilene

•REGION 10 – El Paso

•REGION 11 – Corpus Christi

 

Texas divided into regions

If an agency is Medicare certified, all of its counties must be contiguous.

Section 12 Ownership and Control Interest Disclosure

In section 12, check the type of organizational structure of your agency.  If you are hospital based please check the box on the application. You may learn more about the definitions of these types of ownership companies by clicking here.

Check one of the boxes on the application for Profit or Nonprofit.

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Section 12(a) of Form 2021

Do not forget to submit the copy of the Secretary Franchise Tax Certification of Account Status.

 

Organizational chart

Section 12 Ownership and Control Interest Disclosure

In section 12b (i), you must disclose information about the owner/applicant and affiliates. Fill out the application with each owner applicants information.  Report both the organization/individual and stockholders/investors that have ownership in the applicant/agency.

In this section you must disclose information about the owner/applicant and affiliates. Report both the organization/individual and stockholders/investors that have ownership in the applicant/agency. The individual(s) percentage of ownership must equal 100%.

This includes:

  • All stockholders (individual persons and any business entities) owning a percentage of the agency.
  • All directors, partners, members, officers, executives and trustees.
  • All entities and persons who have controlling/directional/governing/managing interest in owner/applicant.

Note: All partners within a partnership must be reported. This applies to both general and limited partnerships. For instance, if a limited partnership has several limited partners and each of them owns 1% interest in the partnership, each limited partner must be reported in this application by name, address and Social Security number. If the owner has purchased a franchise, indicate the name, address and Social Security number of the purchaser.

Section 12 Ownership and Control Interest Disclosure

 

On the application section 12b (ii), complete a separate section for each legal business entity and disclose the name, address, Tax ID number (EIN) and contact person information for the management company. DADS requires that management company controlled organizations be reported. This is any organization that exercises operational or managerial control over the day-to-day operations of the HCSSA. 

 

If the facility/agency is operated by or proposed to be operated under a management company, enter the following management company information.  On the application complete a separate page for each legal business entity and disclose the name, address, tax ID number and contact person information for the management company.

 

DADS requires that management company controlled organizations be reported. This is any organization that exercises operational or managerial control over the day-to-day operations of the HCSSA.

 

Note: if this section does not apply, check the box on the application and skip to Item 12. b. (iv).

 

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Section 12 b (ii) Form 2021

Section 12 Ownership and Control Interest Disclosure

On the application section 12b (iii), please complete each space with the requested information.

 

On the application please provide the following information for applicable stockholders and staff of the management company, including:

  • All stockholders. Please list any stockholders of the management company who are also stockholders listed in Item 12 b. (i) or Item 12 b. (vi) first, followed by stockholders with only an ownership interest in this corporation.
  • All directors, partners, members, officers, executives and trustees.
  • All entities and persons who have controlling/directional/governing/managing interest in the management company.

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Section 12 b (iii) Form 2021

Section 12 Ownership and Control Interest Disclosure

On the application section 12b (iv), list the information requested for each officer, director or partner.

On the application list the name, business address and Social Security number of all officers for the applicant's board of directors/governing body. This section applies to all agencies that are corporations, limited liability companies, limited partnerships or trust foundations. All agencies with the category of Licensed and Certified Home Health Services, Licensed and Certified Home Health Services with Dialysis, or Hospice Services must have a board of directors/governing body.

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Section 12 b (iv) Form 2021

Section 12 Ownership and Control Interest Disclosure

On the application section 12b (v), list the information requested for each facility/agency license held in any state.

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Section 12 b (v) Form 2021

Map of the United States

Section 12 Ownership and Control Interest Disclosure

On the application section 12b (vi), list the information requested if the owner/applicant is a subsidiary of another organization.

 

 

Section 12 b (vi) Form 2021

Texas outline

Section 12 Ownership and Control Interest Disclosure

On the application section 12b (vii), provide the information requested for those individuals with ownership interest in the parent organization.

Section 12 (vii) of Form 2021

Section 12 b (vii) Form 2021

Texas outline

Section 13 Adverse Legal History

DADS requires in section 13 (a) that the owner/applicant must disclose the following data concerning each owner/applicant, applicant's affiliates and the managers of the applicant/owner. Check the appropriate boxes on the application and provide needed attachments if you answered yes. Scroll over the image for more information. Scroll over the image below for more information.

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Section 13 (a) of Form 2021

Picture of a law book and gavel

Don't forget any attachments.

For more information about criminal history click here.

Section 13 Adverse Legal History

DADS requires in section 13 (b) that an owner/applicant disclose the information below for certain individuals listed below. Check the appropriate boxes on the application and provide needed attachments if you answered yes.Scroll over the image for more information.

Section 13 (b) of Form 2021

Section 13 Adverse Legal History

DADS requires in section 13(c) that an owner/applicant disclose the information listed below. This includes all of the individuals identified in Item 12b (i), as well as the administrator, alternate administrator and chief financial officer. Check the appropriate boxes on the application and provide needed attachments if you answered yes.

Section 13(c) of Form 2021

Section 14 Affidavit for Application

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Affidavit for Application Form 2021

This affidavit attests that you have read, understand and are able to meet the requirements listed in Title 40 Texas Administrative Code Chapter 97 and Health and Safety Code Chapter 142. Complete the affidavit.

 

The affidavit:

  • must be signed by the owner or a person having signing authority for all types of applications;
  • attests that you are over 18 years of age and personally acquainted with all the facts stated in your application; and
  • requires you to have a notary.

symbol of a notary seal

Section 14 Affidavit for Capability

This affidavit attests that you have read, understand and are able to meet the requirements listed in Title 40 Texas Administrative Code Chapter 97 and Health and Safety Code Chapter 142. Complete the affidavit.

 

Affidavit for Capability Form 2021

The affidavit:

  • must be signed by the owner or a person having signing authority for all types of applications;
  • attests that you are over 18 years of age and personally acquainted with all the facts stated in your application; and
  • requires you to have a notary.

 

Person taking an oath Click on the word affidavit above for a

copy of this affidavit.

Section 14 Affidavit of Financial Solvency

This affidavit attests that your agency as the provider of services states and declares that it has the financial resources to meet its proposed budget and to provide the services required during the term of the license.

Complete the affidavit.

 

Affidavit of Financial Solvency of Form 2021

The affidavit:

  • must be signed and completed by the owner or a person having signing authority for initial and CHOW applications;
  • attests that you are over 18 years of age and personally acquainted with all the facts stated in your application; and
  • requires you to have a notary.

 

Person taking an oath Click on the word affidavit above for a copy of this affidavit.

 

Document Checklist for Initial and CHOW Applications

The following documents must be submitted with the application packet:Checkmark box

  • Completed application Form 2021; 
  • Completed Affidavit of Capability;
  • Completed Affidavit of Financial Solvency;
  • Non-refundable licensing fee;
  • Completed entity documents for business organizations. A legal entity could be a corporation, limited partnership, general partnership, sole proprietor, limited liability company, city, county, state or federal government authority or hospital district/authority or a trust, living trust, estate; 
  • Franchise tax account status from the State Comptroller's Office or exemption letter;
  • Proof of National Provider Identification Number;
  • Proof of Tax ID Number (EIN);
  • Organizational structure of the agency;
  • Job descriptions for the agency administrator and alternate administrator;
  • Job description for the supervising nurse and alternate supervising nurse;
  • A written plan to provide annual continuing education for management personnel;
  • Current resume or curriculum vitae for the agency administrator and the alternate administrator;
  • Current resume or curriculum vitae for the supervising nurse and alternate supervising nurse;
  • Presurvey Conference CBT certificates;
  • Form 2022, criminal history check, for each owner, administrator, alternate administrator and chief financial officer;
  • Copies of the initial 8 hour administrator training certificates; and
  • Written plan for the orderly transfer of care for the patients/clients.

 

 

Additional information concerning these documents maybe found on pages 17-18 of Form 2021 and by clicking here.

 

Document Checklist for CHOW Applications

 

The following additional  documents must be submitted for a CHOW:Checkmark box

  • Notarized copy of previous owner's affidavit;
  • Notarized copy of sales agreement;
  • Notarized copy of bill of sale;
  • Accreditation status; and
  • Contract status with all state agencies.

 

Additional information concerning these documents maybe found on page 18 of Form 2021 and by clicking here.

 

Document Checklist for Medicare Applications

 

The following documents must be submitted:

  • Health Insurance Benefit Agreement CMS Form 1561;
  • Medicare Certification Civil Rights Information Request Form and Attachments; and
  • Form HHS-690, Assurance of Compliance.

 

If you are requesting hospice you must also complete this form:

  • Hospice Request for Certification in the Medicare Program Form 417.
  • Hospice information can also be found by clicking here.

 

Additional information concerning these documents maybe found on page 18 of Form 2021.Checkmark box

 

Document Checklist for Renewal Applications

 

The following documents must be submitted:Checkmark box

  • Completed Form 2021 application;
  • Non-refundable licensing fee of $1,750;
  • Letter of accreditation (if applicable);
  • Contract program and contract numbers (if applicable);
  • Completed Form 2022, Criminal History Check;
  • Current resume or curriculum vitae of the agency's administrator and alternate administrator;
  • Current resume or curriculum vitae of the agency's supervising nurse/therapist and alternate supervising nurse/therapist;
  • Proof of Tax ID Number; and
  • National Provider Identification number.

 

In addition, one of the following must be submitted: (as filed with the Texas Secretary of State)

  • copy of the articles of incorporation and assumed name certificate (if applicable);
  • copy of the articles of organization and assumed name certificate (if applicable);
  • copy of the informal or formal partnership agreement and assumed name certificate (if applicable); or
  • copy of the will, letters, testamentary or trust agreement.

 

Additional information concerning these documents maybe found on page 19 of Form 2021 and by clicking here.

 

Where to Send Application Packet

Regular Mail

 

Regulatory Services Accounts Receivable

Mail Code E-411

Department of Aging and Disability Services

P. O. Box 149030

Austin, TX  78714-9030

Next day delivery image

Mail box image

Overnight Delivery

 

Regulatory Services Accounts Receivable

Mail Code E-411

Department of Aging and Disability Services

701 West 51st St.

Austin, TX  78751

 

Application Processing Time Frames

An application from an agency is processed in accordance with the following general time frames:

  • If DADS receives an incomplete application, the DADS HCSSA Licensing Unit will notify the HCSSA applicant in writing of any deficient items in the application. The applicant must respond with complete and correct information within 30 days from the date of the letter or the application will be denied.

 

Clock and calendar image

  • DADS will issue a license or deny the application within 45 days of receipt of a complete application, which includes all required documentation and fees.  The processing of the application with DADS mail room and DADS Account Receivable could take up to 10 days from the date mailed.

 

Test your Knowledge

 DIrections: Answer each question. At the end of the quiz please clck on the answer button to see your score.

Congratulations!

 

You have completed this presentation. Take time to review the application and to ensure that all the required documentation is in the application packet before mailing.

 

The secret of getting ahead is getting started by Mark Twain