Purpose
Form 5872 is completed by individuals and organizations applying to contract with the Texas Health and Human Services Commission (HHSC) to confirm they read the Pre-Application Orientation Guide required for the following contracts:
Community Living Assistance and Support Services (CLASS)
Day Activity and Health Services (DAHS)
Primary Home Care/Family Care/Community Attendant Services (PHC/FC/CAS)
Procedure
Form 5872 is prepared for a new contract.
Form Retention
Contact Administration Handbook.
Carefully read the instructions. Errors and omissions will cause delays in processing Form 5872.
Legal Entity Information
Legal Entity Name Enter the full, legal name of the entity, exactly as it was chartered, filed, registered or otherwise legally declared.