Provider Contract Application

Thank you for your interest in joining us in supporting youth and families in Region 5 with the Texas Family Care Network. The first step to contract with us is to complete our online application.

Select the Services/Programs that your agency offers(Required)

Agency Information

Does your agency/facility hold a permit in Texas?(Required)
Is your agency on heightened monitoring?(Required)
Has your agency, in the last 12 months, been on any formal corrective action plan with DFPS, licensing, or third-party auditor?(Required)
Does your agency/facility have a current Provider Agreement with DFPS or a Texas SSCC?(Required)
Does your agency/facility currently bill Medicaid for any services?(Required)
Does your agency/facility have any revocation or suspensions as a Medicaid Provider?(Required)
Does your agency/facility have any license actions (i.e. suspensions, revocation, sanctions, etc.)?(Required)
Does your agency have any judgement or settlements against the agency/facility that pertain to child welfare or behavior?(Required)
Is your agency/facility accredited? (COA, JCAHO, etc.)(Required)

Liability Questions

Has an individual, agency, or member of the staff been named in any malpractice action in the last five (5) years?(Required)
Has the malpractice insurance of the individual, agency, or staff member been canceled, non-renewed or special rated in the last five (5) years?(Required)
Has any government, private accreditation, or licensing agency investigated, suspended, revoked, or taken any other action against the individual/organization or staff member licensed to practice in the last five (5) years?(Required)
Has the individual, agency, or staff member had, or does it currently have pending, any litigation, claims, protests, suspensions, placement holds, action or proceeding, whether judicial, arbitral, or administrative, and any government investigations or inquiries which affect or may affect any grants, contracts, licenses, accreditations, property, or business involving either applicant or its employees in the last five (5) years?(Required)
At any time, have any memberships in professional organizations or accreditations by national or state bodies been revoked, denied or suspended by others or voluntarily given up by the individual, agency, or members of the organization?(Required)
Has the individual, agency, or staff members been removed, sanctioned, or suspended from membership in a professional association for violation(s) of an ethical code of practice in the last five (5) years?(Required)
Does your agency/facility have professional and general liability insurance coverage?(Required)
Does your agency require criminal history background screenings on all staff prior to hiring?(Required)

Thank you for completing this application. We will review your information and contact you to discuss next steps in the contracting process.

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