Texas Department of Aging and Disability Services
Form 2192 February 2011
Certification Regarding Licensure Requirements Legal Name of Entity
Home and Community Support Services Agency (HCSSA) License Number(s) List License Number(s):
Provide the following information regarding the above license number(s): 1. For CBA/HCSS, PHC/FC and/or CWP/HCSS, has the agency held the correct category of licensure for at least one year? ................................................................................................................................................................................
Yes
No
2. Has an on-site health survey of the HCSSA been conducted? .........................................................................................
Yes
No
3. Are all of the above listed HCSSA licenses eligible to be renewed?.................................................................................
Yes
No
4. Are any of the HCSSA licenses under a monitoring agreement with licensure? ...............................................................
Yes
No
5. Do any of the HCSSA licenses have a licensure revocation action pending? ..................................................................
Yes
No
6. Do any of the HCSSA licenses have a Level B administrative penalty pending? .............................................................
Yes
No
7. Have any of the HCSSA licenses had any Level B administrative penalty imposed in the prior 12 months? ...................
Yes
No
8. Has the HCSSA provided attendant or home health services to at least 10 individuals in the DADS region in which a contract is requested? ...................................................................................................................................................
Yes
No
9. Has the HCSSA provided ongoing attendant or home health services to at least 2 individuals during a 60-day block of time in the DADS region in which a contract is requested? ..........................................................................................
Yes
No
10. Has the HCSSA provided attendant or home health services for a total of at least 500 hours during the 12 months immediately preceding this application in the DADS region in which a contract is requested? .........................................
Yes
No
I certify that the above information is true and correct. I understand that the above information may be verified by DADS. I understand that misrepresentation may result in the denial/termination of my contract and/or prosecution under applicable state or federal statutes.
Signature–Authorized Representative
Date
Name of Authorized Representative (Type or Print)
Subscribed and sworn before me, County of
, on the
, a Notary Public for the ,
day of (month)
Official Notary Seal (must be original seal)
(year)
Notary Public
County of: State of:
.