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Content Overview

The Texas form, specifically designed for the Home and Community Support Services Agencies Licensure, plays a crucial role in ensuring that agencies meet the necessary eligibility criteria as outlined by state regulations. This comprehensive document requires the submission of personal and professional details about key individuals associated with the agency, including the owner, administrator, alternate administrator, and chief financial officer. Each section of the form prompts the applicant to provide essential information such as names, dates of birth, race or ethnicity, and social security numbers. Additionally, it emphasizes the importance of accuracy and honesty, as the applicant must certify that the information provided is true to the best of their knowledge. This form is not only a tool for licensure but also serves to facilitate criminal history checks, ensuring the safety and well-being of the communities these agencies serve. Furthermore, it outlines the process for submitting the form, whether for initial applications, renewals, or management changes, and provides essential contact information for follow-up inquiries. Understanding the significance and requirements of this form is vital for anyone involved in the operation of home and community support services in Texas.

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Form Specifications

Fact Name Description
Governing Law This form is governed by the Texas Health and Safety Code, Chapter 142, specifically §142.004, which outlines licensure application requirements for Home and Community Support Services Agencies.
Purpose The information collected on this form is used solely to meet the eligibility criteria for licensure as mandated by Texas law.
Submission Details Applicants must submit this form with initial, renewal, and Change of Ownership (CHOW) applications, as well as with any management changes.
Contact Information For questions or corrections regarding the information obtained from the Texas Department of Public Safety, individuals should contact the Crime Records Service in Austin.
Rights of Individuals Individuals have the right to request access to their information collected by the Texas Department of Aging and Disability Services and to seek corrections for any inaccuracies.

Texas: Usage Guidelines

Filling out the Texas Criminal History Check Form is an important step in ensuring compliance with licensing requirements. This form gathers essential information about individuals involved in home and community support services. Below are the steps to guide you through the process of completing the form accurately.

  1. Obtain the Texas Criminal History Check Form from the Texas Department of Aging and Disability Services website or your local office.
  2. Begin by filling in the Agency Name at the top of the form.
  3. Provide the Physical Address including the street name, city, state, and ZIP code.
  4. In the section for Owner Name, enter the last name, first name, and middle name of the owner.
  5. Fill in the Current License No. and the Area Code and Telephone No. for the owner.
  6. Indicate whether the owner is an Administrator by marking "Yes" or "No."
  7. List any Other Names Used by the owner, including married or maiden names and aliases. If necessary, use an addendum for additional names.
  8. Enter the Date of Birth in the format mm/dd/yyyy and specify the Race/Ethnicity.
  9. Repeat steps 4 through 8 for the Administrator Name and the Chief Financial Officer Name, providing all requested details.
  10. In the section for Sex, select either "Male" or "Female" for each individual listed.
  11. At the bottom of the form, sign and date to certify that the information provided is accurate and truthful.
  12. Review the completed form for any errors or omissions before submission.
  13. Submit the form by mail or fax to the Texas Department of Aging and Disability Services at the address provided on the form.

Once you have submitted the form, the Texas Department of Aging and Disability Services will process it as part of the licensure eligibility criteria. Ensure you keep a copy for your records, as it may be needed for future reference or follow-up.

Your Questions, Answered

What is the purpose of the Texas Criminal History Check Form?

The Texas Criminal History Check Form is designed to ensure that individuals involved in home and community support services meet the licensure eligibility criteria set by the Texas Health and Safety Code. This form collects personal information from owners, administrators, and chief financial officers of agencies, allowing the Texas Department of Aging and Disability Services to conduct necessary background checks.

Who needs to complete this form?

This form must be completed by the owner, administrator, and chief financial officer of a home and community support services agency. If there are any alternate administrators or additional individuals involved in the agency's management, their information should also be included. Accurate and complete information is essential for the licensure process.

What information is required on the form?

The form requires personal details such as names (including any aliases), dates of birth, race/ethnicity, sex, and social security numbers. Additionally, it asks for the current license number and contact information. It's important to provide all applicable information accurately to avoid delays in processing.

How should the completed form be submitted?

Once the form is completed, it should be submitted either by mail or fax to the Texas Department of Aging and Disability Services. The mailing address is Regulatory Services - Agency Licensing, Mail Code E-342, P.O. Box 149030, Austin, TX 78714-9030. The fax number for submissions is 512-438-2731. Make sure to send the form along with initial, renewal, and change of ownership applications.

What should I do if I find incorrect information on my background check?

If you discover that the information obtained from the Texas Department of Public Safety (DPS) is incorrect, you should contact the Texas DPS Crime Records Service. Their mailing address is P.O. Box 4143, Austin, TX 78765-4143. It is crucial to address any discrepancies promptly to ensure accurate records are maintained.

Do I have the right to access and correct my information?

Yes, you have the right to request access to the information that the Texas Department of Aging and Disability Services obtains about you. You can also ask for corrections if any information is found to be incorrect. For more details, you can contact Regulatory Services - Agency Licensing at 512-438-2630.

Common mistakes

  1. Incomplete Information: Failing to fill in all required fields can lead to delays. Ensure that every section is completed accurately.

  2. Incorrect Names: Miswriting names, especially for aliases or previous names, can cause issues. Double-check spelling and ensure all names are included.

  3. Missing Signatures: Not signing the form can result in rejection. Always sign and date the document before submission.

  4. Wrong Dates: Entering incorrect dates of birth or other critical dates can lead to confusion. Verify that all dates are accurate.

  5. Neglecting to Use Addendum: If you have multiple aliases or names, failing to use the addendum can lead to incomplete submissions. Make sure to include all necessary information.

  6. Ignoring Contact Information: Not providing a current phone number or address can hinder communication. Always include accurate contact details.

  7. Submitting Without Review: Sending the form without a final review can lead to overlooked errors. Take the time to review everything before submission.

  8. Failure to Keep Copies: Not retaining a copy of the submitted form can cause issues if questions arise later. Always keep a record of your submission.

Documents used along the form

When applying for licensure as a Home and Community Support Services Agency in Texas, several additional forms and documents may be necessary to ensure a complete application. These documents help provide a comprehensive overview of the agency and its personnel. Below is a list of commonly used forms that accompany the Texas Department of Aging and Disability Services Agency Name Home and Community Support Services Agencies Licensure Criminal History Check Form.

  • Agency License Application Form: This document is essential for the initial licensing process. It gathers information about the agency's structure, services offered, and compliance with state regulations. Submitting this form is crucial for obtaining a valid operating license.
  • Background Check Authorization Form: This form authorizes the Texas Department of Public Safety to conduct background checks on key personnel within the agency. It is important for ensuring that all individuals in positions of authority meet the necessary legal requirements for licensure.
  • Management Change Notification Form: Whenever there are changes in the agency's management or ownership, this form must be submitted. It ensures that the Texas Department of Aging and Disability Services is informed of any alterations that may affect the agency's operations or compliance status.
  • Financial Disclosure Form: This document provides detailed financial information about the agency. It includes data on funding sources, expenditures, and financial management practices. This form is vital for assessing the agency's financial stability and ability to provide services.

Completing and submitting these forms alongside the primary Criminal History Check Form is essential for a smooth licensing process. Each document serves a specific purpose and helps maintain the integrity and safety of the services provided to the community. Ensuring all forms are filled out accurately and submitted on time will facilitate a more efficient review by the licensing authority.

Similar forms

  • Criminal Background Check Form: Similar to the Texas form, this document collects personal information to verify an individual's criminal history. Both forms aim to ensure safety and compliance in licensed environments.
  • Professional License Application: Like the Texas form, this application requires detailed personal information, including names and dates of birth, to assess eligibility for professional licensure.
  • Employment Application: This document, much like the Texas form, gathers information about an applicant's background, including aliases and previous names, to evaluate their qualifications for a job.
  • Healthcare Provider Credentialing Application: Similar in purpose, this application verifies the credentials of healthcare providers, requiring personal and professional details to ensure compliance with regulations.
  • Child Care Provider Background Check Form: This form shares similarities with the Texas form by requiring personal information to conduct background checks on individuals working with children.
  • Nonprofit Organization Registration Form: Like the Texas form, this document collects information about key individuals in the organization to ensure transparency and compliance with state regulations.
  • Real Estate License Application: This application is similar in that it requires personal identification details to assess the applicant's eligibility for a real estate license.
  • Insurance Agent License Application: This document, much like the Texas form, collects essential personal information to determine if the applicant meets the requirements for an insurance license.
  • Food Handler Certification Application: Similar to the Texas form, this application gathers personal information to ensure that individuals meet health and safety standards in food service.

Dos and Don'ts

When filling out the Texas form, consider the following guidelines:

  • Ensure that all information is printed clearly and legibly.
  • Double-check the accuracy of names, dates, and other personal details.
  • Use the correct format for dates (mm/dd/yyyy) to avoid confusion.
  • Include all applicable aliases, including married or maiden names.
  • Sign and date the form where indicated to validate your submission.
  • Keep a copy of the completed form for your records.
  • Submit the form via the specified method (mail or fax) to the correct address.

Avoid these common mistakes:

  • Do not leave any required fields blank; fill in all applicable information.
  • Avoid using abbreviations or nicknames for names.
  • Do not submit the form without verifying all details for accuracy.
  • Refrain from using correction fluid or tape on the form.
  • Do not forget to include any necessary addenda for additional names.
  • Avoid submitting the form to an incorrect address or department.
  • Do not ignore the submission deadline; timely submission is crucial.

Misconceptions

Understanding the Texas form for Home and Community Support Services Agencies can be tricky. Here are some common misconceptions that people often have:

  • All personal information is optional. Many believe that they can skip sections on the form, but all requested information is necessary for licensure eligibility.
  • The form only needs to be filled out once. Some think they only need to submit the form during initial application, but it must also be submitted for renewals and management changes.
  • Submitting incorrect information is not a big deal. Many underestimate the importance of accuracy. Providing false information can lead to serious consequences, including denial of the application.
  • Only the owner’s information is required. Some individuals think that only the owner needs to provide details, but information for administrators and financial officers is also essential.
  • The form is only for new applicants. Existing agencies must also complete the form when there are changes in management or ownership.
  • There are no rights regarding personal information. A common misconception is that individuals have no control over their data. In fact, you can request to see and correct information collected about you.
  • Faxing the form is not a valid submission method. Some believe that only mailing is acceptable. However, faxing is also a legitimate option for submitting the form.
  • Race and ethnicity are not relevant. Some people think that these details are unnecessary, but they are required for demographic purposes and must be accurately reported.
  • Once submitted, the information cannot be changed. Many assume that submitted information is final. However, you can request corrections if you find inaccuracies later.

Being aware of these misconceptions can help ensure a smoother process when dealing with the Texas form. Always double-check your information and understand your rights regarding your personal data.

Key takeaways

Here are some key takeaways regarding the Texas Criminal History Check Form:

  • Complete All Sections: Ensure that every applicable section is filled out accurately. This includes personal information for all listed individuals.
  • Use Full Names: Provide full names, including any married or maiden names, and aliases, as necessary.
  • Submit with Applications: The form must be submitted alongside initial, renewal, and change of ownership applications.
  • Signature Required: A signature is mandatory to certify that the information provided is true and correct.
  • Correcting Information: If any information is found to be incorrect, you have the right to request a correction.
  • Contact Information: For any discrepancies with the Texas Department of Public Safety, contact their Crime Records Service directly.
  • Privacy Rights: You have the right to request and review the information obtained about you by the Texas Department of Aging and Disability Services.
  • Submission Methods: The form can be submitted by mail or fax to the designated address provided in the instructions.