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FISCAL YEAR 2012 POLICY MANUAL

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					      FISCAL YEAR 2012

DEPARTMENT OF STATE HEALTH SERVICES


PRIMARY HEALTH CARE PROGRAM




               2012
       POLICY MANUAL
    SECTION ONE


GENERAL INFORMATION
                                                                         SECTION ONE
                                                                GENERAL INFORMATION
                                                                                              1


Chapter 31,   In the early 1980’s, economic recession and c ost containment measures
Health &      on the part of employers and government agencies led to a decrease in the
Safety Code   availability and ac cessibility of health care services for many Texans. A
              gubernatorial and l egislative task force identified the provision of primary
              health care to the medically indigent as a major priority. T he task force
              recommended the following:

                 •   A range of primary health care services shall be made available to
                     the medically indigent residing in Texas.
                 •   The Department of State Health (DSHS) shall provide or contract to
                     provide primary health care services to the medically indigent.
                     These services should complement existing services and/or should
                     be provided where there is a scarcity of services.
                 •   Health education should be an i ntegral component of all primary
                     care services delivered to the medically indigent population.
                     Preventive services should be m arketed and made accessible to
                     reduce the use of more expensive emergency room services.

              These recommendations become the basis of the indigent health care
              legislative package enacted by the 69th Texas Legislature in 1985. T he
              Primary Health Care Services Act, HB 1844, was part of this legislation and
              is the statutory authority for Primary Health Care Services (PHC)
              administered by DSHS. The Act delineates the specific target population,
              eligibility, reporting, and coordination requirements for PHC. Internet links
              to the relevant Health and Safety Code and Texas Administrative Code can
              be found in Appendix C of this manual.

              Support for the Primary Health Care Services Act is broad-based and
              includes local government associations, health professional organizations,
              religious organizations, citizen coalitions, and consumers. It is recognized
              that primary health care is of major importance in reducing the burden of
              unnecessary illness and premature death, as well as reducing overall
              health care expenditures incurred by expensive crisis-oriented care.


PHC Rules     The state rules for Primary Health Care Services in Texas can be found in
              the Texas Administrative Code (TAC), Title 25, Part 1, Chapter 39,
              Subchapter A. Section 39.2 of the Texas Administrative Code (TAC) states
              that PHC services include:

                 •   Diagnosis and treatment
                 •   Emergency services
                 •   Family planning services
                 •   Preventive health services, including immunizations
                 •   Health education
                 •   Laboratory, x-ray, nuclear medicine, or other appropriate diagnostic
                     services



                                                                           September 2011
                                                                           SECTION ONE
                                                                  GENERAL INFORMATION
                                                                                                2

PHC Rules        •   Nutrition services
(continued)      •   Health screening
                 •   Home health care
                 •   Dental care
                 •   Transportation
                 •   Prescription drugs and devices, and durable supplies
                 •   Environmental health services
                 •   Podiatry services
                 •   Social Services

              TAC §39.3 and 39 .4 state that, at a minimum, a P HC contractor must
              provide the following six priority primary health care services either directly
              or through agreements or subcontracts with other providers:

                 •   Diagnosis and treatment
                 •   Emergency services
                 •   Family planning services
                 •   Preventive health services, including immunizations
                 •   Health education
                 •   Laboratory, x-ray, nuclear medicine, or other appropriate diagnostic
                     services

              The Primary Health Care Services Act seeks to provide access to primary
              health care services for those individuals, at or below 150% of the Federal
              Poverty Level (FPL), who are unable to access the same care through
              other funding sources or programs. Contractors must assure that the
              services they provide either directly or indirectly (through a s ystem of
              referrals and/or subcontracts) are accessible to clients in terms of cost,
              scheduling, distance, and cultural sensitivity.




Definitions   Below are some general definitions of terms or phrases that are used
              throughout this manual.

              Age – For a child to be counted as part of the household, the child must be
              under 18 years of age and unm arried. The provider staff should terminate
              the child’s eligibility at the end of the month the child become 18 unless the
              child:
                  • Is a f ull-time student (as defined by the school) in high school,
                      attends an accredited GED class, or regularly attends vocational or
                      technical training as an equivalent to high school attendance, and

                 •   Is expected to graduate before or during the month of his/her 19th
                     birthday. If the child does not meet the above criteria, he/she will
                     be considered a separate household of one.




                                                                             September 2011
                                                                          SECTION ONE
                                                                 GENERAL INFORMATION
                                                                                               3

Definitions   Client – An individual who has been screened, determined to be eligible for
(continued)   services, and has successfully completed the eligibility process.

              Community Assessment – Tool used to identify factors that affect the
              health of a population and to determine the availability of resources within
              the community to impact these factors.

              Contractor – The entity the Department of State Health Services has
              contracted with to provide services. The contractor is the responsible entity
              even if there is a subcontractor involved who actually provides the services.

              Co-Payment (co-pay) – Monies collected directly from clients for services.
              The amount collected each month should be deduc ted from the Monthly
              Purchase Voucher (Form B -13) and is considered program income.

              Dental Services – Periodic exams, fillings, prophylactic cleaning, etc.
              performed in a dental office or clinic.

              Department of State Health Services (DSHS) – The agency responsible
              for administering physical and mental health-related prevention, treatment,
              and regulatory programs for the State of Texas.

              Diagnosis – The recognition of disease status determined by evaluating
              the history of the client and the disease process, and the signs and
              symptoms present. ( Determining the diagnosis may require microscopic
              (i.e. culture), chemical (i.e., blood tests), and/or radiological examinations
              (x-rays).

              Eligibility Date – Date the individual submits a completed application to
              the provider. The eligibility expiration date will be twelve months from the
              eligibility date.

              Emergency Services – Services provided to individuals when there is an
              unexpected health condition that requires immediate attention.

              Environmental Health – The provision of treating a person’s surroundings
              in regards to a health condition.

              Family Composition/Household – A person living alone or a group of two
              or more persons related by birth, marriage (including common law) or
              adoption, who reside together and who are legally responsible for the
              support of the other person.

              Family Planning Services – Assisting women and men in planning their
              families, whether it is to achieve, postpone, or prevent pregnancy. Family
              planning services include the following: p regnancy test (if indicated),
              health history, risk assessment, physical examinations, lab tests,
              counseling/education, and contraceptive supplies.




                                                                            September 2011
                                                                           SECTION ONE
                                                                  GENERAL INFORMATION
                                                                                                4

Definitions   Federal Poverty Level (FPL) – The set minimum amount of income that a
(continued)   family needs for food, clothing, transportation, shelter and ot her
              necessities. In the United States, this level is determined by the
              Department of Health and Human Services. FPL varies according to family
              size. The number is adjusted for inflation and reported annually in the form
              of poverty guidelines. Public assistance programs, such as Medicaid in the
              U.S., define eligibility income limits as some percentage of FPL.

              Fiscal Year – State fiscal year, September 1 – August 31.

              Health and Human Services Commission (HHSC) – State agency that
              has oversight responsibilities for designated Health and H uman Services
              agencies, including DSHS, and adm inisters certain health and human
              services programs including the Texas Medicaid Program, Children’s
              Health Insurance Program (CHIP), and Medicaid waste, fraud, and abuse
              investigations.

              Health Screening – The provision of tests, i.e. blood glucose, serum
              cholesterol, fecal occult blood, as a means
              For determining the need for intervention and perhaps more
              comprehensive evaluation.

              Health Service Region – For administrative purposes, DSHS has grouped
              counties within a s pecified geographic area into 11 H ealth Service
              Regions.

              Home Health Care – Services include Registered Nurse (RN) visits for
              skilled nursing observation, assessment, evaluation, and treatment
              provided by a physician specifically requests the RN visit for this purpose.
              A home health aide to assist with administering medication is also covered.

              Laboratory, X-Ray, or other Appropriate Diagnostic Services – Studies
              or tests ordered by the client’s health care practitioner(s) to evaluate an
              individual’s health status for diagnostic purposes.

              Medicaid – Title XIX of the Social Security Act; reimburses for health care
              services delivered to low-income clients who meet eligibility guidelines.

              Minor – A person who has not reached his/her 18th birthday and who has
              not had the classification of minor removed in court or who is not or never
              has been married or recognized as an adult by the State of Texas.

              Nutritional Services – The provision of services to identify the nutritional
              status of an individual, and i nstruction which includes appropriate dietary
              information based on the client’s needs, i.e. age, sex, health status, culture.
              Information may be pr ovided on an i ndividual, one- to-one basis, or to a
              group of individuals.




                                                                             September 2011
                                                                           SECTION ONE
                                                                  GENERAL INFORMATION
                                                                                                 5

Definitions   Outreach – Activities that are conducted with the purpose of informing and
(continued)   educating the community about services and i ncreasing the number of
              participants.

              Podiatry Services – The study and care of the foot, including its anatomy,
              pathology, and medical/surgical treatment.

              Prescription Drugs and Devices and Durable Supplies – Medically
              necessary pharmaceuticals, medical supplies (capable of withstanding
              wear) which are needed for the treatment of a diagnosed condition.

              Presumptive Eligibility – Short-term availability and access to health care
              services (90 days) when an immediate medical need exists as determined
              by a m edical professional and t he client screens potentially eligible for
              services.

              Preventive Health Care Services – The major emphasis is placed on
              guarding or defending an individual or group against specific illness or
              injury. Included are immunizations, risk assessments, health histories, and
              baseline physicals for early detection of disease and r estoration to a
              previous state of health, and pr evention of further deterioration and/or
              disability.

              Program Income – Monies collected directly by the contractor/provider for
              services provided under the grant award.

              Provider – An individual clinician or group of clinicians who provide
              services.

              Re-certification – The process of re-screening and determining eligibility
              for the next year.

              Resident Alien – A person who is not an U.S. citizen, and has an
              immigration document.

              Service – Any client encounter at a facility that results in the client having a
              medical or health-related need met.

              Social Services – The provision of counseling and guidance; assistance to
              client and family in locating, accessing, and utilizing appropriate community
              resources.

              Texas Resident – An individual who resides within the geographic
              boundaries of the state.

              Transportation – Services provided to a client for the purpose of receiving
              a required health care service. Transportation could be provided via
              private vehicle, public transportation, project site vehicle, or emergency
              medical vehicle.



                                                                              September 2011
                                                                      SECTION ONE
                                                             GENERAL INFORMATION
                                                                                        6

Definitions   Treatment – Any specific procedure used for the cure or the improvement
(continued)   of a disease or pathological condition.

              Undocumented Alien – A person who is not an U.S. citizen, and has no
              immigration documentation.

              Unduplicated Client – Clients are counted only regardless of the number
              of services they receive. One client seen four times is counted as one
              unduplicated client and a family of three seen once is counted as three
              unduplicated clients.


Acronyms

              Acronym          Term
              ADA              Americans with Disabilities Act
              BCCS             Breast and Cervical Cancer Services
              CAM              Complementary and Alternative Medications
              CDSB             Contract Development and Support Branch
              CFTR             Cystic Fibrosis Transmembrane Conductance
                               Regulator
              CHIP             Children’s Health Insurance Program
              CIHCP            County Indigent Health Care Program
              CLIA             Clinical Laboratory Improvement Amendments
              CMB              DSHS Contract Management Branch
              CPR              Cardiopulmonary Resuscitation
              DES              Diethylstilbestrol
              DHHS             U.S. Department of Health and Human Services
              DSHS             Texas Department of State Health Services
              EMR              Electronic Medical Record
              FPL              Federal Poverty Level
              FQHC             Federally Qualified Health Center
              FSR              Financial Status Report
              HIPPA            Health Insurance Portability and Accountability
                               Act of 1996
              HHSC             Texas Health and Human Services Commission
              HPV              Human Papilloma Virus
              HSR              DSHS Health Service Region
              IRB              Institutional Review Board
              LEP              Limited English Proficiency
              MCH              Maternal and Child Health Services
              OTC              Over the Counter
              PMU              DSHS Performance Management Unit
              PHC              Primary Health Care
              PPCU             DSHS Preventive and Primary Care Unit
              QA               Quality Assurance
              QM               Quality Management
              QMB              DSHS Quality Management Branch


                                                                        September 2011
                                             SECTION ONE
                                    GENERAL INFORMATION
                                                          7
RFP     Request for Proposal
RSDI    Retirement Survivors Disability Income
SDO     Standing Delegation Orders
SSA     Social Security Administration
SSDI    Social Security Disability Income
SSI     Supplemental Security Income
STI     Sexually Transmitted Infection
STL     South Texas Lab
TAC     Texas Administrative Code
TANF    Temporary Assistance for Needy Families
TMHP    Texas Medicaid Healthcare Partnership
TMPPM   Texas Medicaid Provider Procedures Manual
WHL     Women’s Health Lab




                                              September 2011
     SECTION TWO


PROGRAM ADMINISTRATION
                                                                             SECTION TWO
                                                                   PROGRAM ADMINISTRATION
                                                                                                  1

Client Access   The contractor must en sure that clients are provided services in a timely
                and non-discriminatory manner. The contractor must:

                      Have a policy in place that delineates the           timely provision of
                       services;
                      Comply with all applicable civil rights laws and re gulations including
                       Title VI of the Civil Rights Act of 1964, the Americans with
                       Disabilities Act of 1990, the Age Discrimination Act of 1975, and
                       Section 504 of the Rehabilitation Act of 1973, and ensure services
                       are accessible to per sons with limited English proficien cy (see:
                       http: www.lep.gov/) and speech or sensory impairments;
                      Have a system to prioritize client’s needs;
                      Have a triage system that utilities qualified staff;
                      Screen clients in a way that is respectful and convenient;
                      Provide referral resources for individuals that cannot be served o r
                       cannot receive a specific service;
                      Continue to provide services to esta blished clients once funds have
                       been expended, and
                      A contractor that is de signated as a FQHC shall operate extended
                       weekend and evening hours a minimum of one time per month.


Abuse           DSHS CHILD ABUSE COMPLIANCE AND MONITORING
Reporting
                Chapter 261 of the Texas Family Code requires child abuse reporting.
                Contractors/providers are required to develop policies and procedures that
                comply with the child abuse reporting guidelines and requirements set forth
                in Chapter 261 and the DSHS Child Abuse, Screening, Documenting and
                Reporting Policy for Contractors/Providers. Contractors must adopt the
                DSHS Child Abuse Screening, Documenting and Reporting Policy for
                Contractors/Providers and develop an internal policy specific to
                how these reporting requirements will be implemented throughout their
                agency, how staff will be trained and how internal monitoring will be done
                to ensure timely reporting.

                The following outlines how the DSHS Quality Management Branch (QMB)
                staff will review for contractor compliance with these requirements.

                Policy – Contractors/providers will be monitored to ensure compliance with
                screening for child abuse and reporting according to Chapter 261 of the
                Texas
                Family Code and the DSHS Child Abuse Screening, Documenting, and
                Reporting Policy for Contractors/Providers.

                Procedures – During site monitoring of contractors by QMB the following
                procedures will be utilized to evaluate compliance:

                1) The contractor's process used to ensure that staff is reporting according
                to Chapter 261 and the DSHS Child Abuse Screening, Documenting and


                                                                                   September 2011
                                                                            SECTION TWO
                                                                  PROGRAM ADMINISTRATION
                                                                                                2

Abuse         Reporting Policy for Contractors will be reviewed as part of the Core Tool.
Reporting     To verify compliance with this item, monitors must review: a) that the
(continued)   contractor adopted the DSHS Policy; b) the contractor's internal policy
              which details how the contractor will determine, document, report, and
              track instances of abuse, sexual or non-sexual for all clients under the age
              of 17 in compliance with the Texas Family Code, Chapter 261 and the
              DSHS Policy; c) the contractor followed their internal policy and the DSHS
              Policy; and d) the contractor documentation of staff training on child abuse
              reporting requirements and procedures.

              2) All records of clients under 14 years of age who are pregnant or have a
              confirmed diagnosis of an STD acquired in a manner other than through
              perinatal transmission or transfusion will be reviewed for appropriate
              screening and reporting documentation as required in the clinic or site
              being visited during a site monitoring visit. The review of the records will
              involve reviewing that the DSHS Child Abuse Reporting Form was utilized;
              a report was made; and the report was made in the proper timeframes
              required by law.

              3) If during the record review process, noncompliance is identified, the staff
              person responsible will be notified and asked to make a report as required
              by law. The agency director will also be notified of the problem.
              Noncompliance will again be identified during the Exit Conference with the
              contractor.

              4) If it is found during routine record review of other records for services
              that a report should have been made as evidenced by the age of the client
              and evidence of sexual activity, the failure to appropriately screen and
              report will be identified as lack of compliance with the DSHS Policy; and
              the QMB will identify the need for the contractor to train staff. Failure to
              report will be brought to the attention of the staff person who should have
              made the report or the appropriate supervisor with a request to immediately
              report. This failure to report will also be discussed with the agency director.

              5) The report sent to the contractor will also indicate the number of
              applicable records reviewed in each clinic and the number of records that
              were found to be out of compliance. This report will be sent to the
              contractor 4 to 6 weeks from the date of the review, which is the
              usual process for Site Monitoring Reports.

              6) The contractor will then be given 6 weeks to respond with written
              corrective actions to all findings. If the contractor has other findings that
              warrant technical assistance or accelerated monitoring review, either
              regional or central office staff will make the necessary contacts. Records
              and/or policies will again be reviewed to ensure compliance with Chapter
              261 and the DSHS Policy requirements. If any subsequent finding of
              noncompliance is identified during a subsequent monitoring or technical
              assistance visit, the contractor will be referred for financial sanctioning.




                                                                                  September 2011
                                                                                SECTION TWO
                                                                      PROGRAM ADMINISTRATION
                                                                                                     3

Abuse             7) If the contractor does not provide corrective actions during the required
Reporting         time period, the contractor will be sent a past due letter with a time period
(continued)       of 10 days to submit the corrective actions. If the corrective actions are not
                  submitted during the time period given, failure to submit the corrective
                  action is considered a subsequent finding of noncompliance and the
                  contractor/provider will be referred for financial sanctioning due to
                  noncompliance with Chapter 261 and the DSHS Policy.

                  8) If a contractor is found to have minimal findings overall but did have
                  findings of noncompliance with Chapter 261 and the DSHS Policy, an
                  additional sanction accelerated monitoring visit solely to review child abuse
                  reporting will not be conducted. For agencies that receive technical
                  assistance visits as a result of a quality assurance review, the agency will
                  again be reviewed for compliance with child abuse reporting for the
                  requirements with which the agency did not comply. In all cases, the
                  corrective actions submitted by the contractor will be reviewed to
                  ensure that the issues have been addressed. Agencies who do not receive
                  a sanction or technical assistance visit will be required to complete the
                  DSHS Progress Report, Compliance with Child Abuse Reporting within 3
                  months after the corrective actions are begun (no later than 6 months from
                  the initial visit). Failure to submit a Progress Report within the required time
                  period or submission of a report that is not adequate constitutes a
                  subsequent finding of noncompliance with the DSHS Child Abuse
                  Screening, Documenting, and Reporting Policy for Contractors/Providers
                  and the contractor will be referred for financial sanctions.

                  Information about this topic is available on the internet at:
                  http://www.dshs.state.tx.us/childabusereporting/default.shtm.

                  .


Confidentiality   All contracting agencies must be in compliance with the U.S. Health
                  Insurance Portability and Accountability Act of 1996 (HIPPA) established
                  standards for protection of client privacy. Information about HIPPA can be
                  found at: http://www.dshs.gov/ocr/hipaa/.

                  Employees and volunteers must be made aware during orientation that
                  violation of the law in regard to confidentiality may result in civil damages
                  and criminal penalties.

                  The client’s preferred method of follow-up to clinic services (cell phone,
                  email, work phone) and preferred language must be documented in the
                  client’s record. (See Client Health Record Section Four, page 8).

                  Each client must receive verbal assurance of confidentiality and an
                  explanation of what confidentiality means (kept private and not shared
                  without permission) and any applicable exceptions such as abuse reporting
                  (See Abuse Reporting, Section Two, page 1).



                                                                                      September 2011
                                                                             SECTION TWO
                                                                   PROGRAM ADMINISTRATION
                                                                                                 4


Non-             DSHS contractors must comply with state and federal anti-discrimination
Discrimination   laws, including without limitation:

                    1. Title VI of the Civil Rights Act of 1964 (42 U.S.C. §2000d et seq.);
                    2. Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. §794);
                    3. Americans with Disabilities Act of 1990 (42 U.S.C. §12101 et seq.
                    4. Age Discrimination Act of 1975 (42 U.S.C. §§6101-6107);
                    5. Title IX of the Education Amendments of 1972 ( 20 U.S.C. §§1681-
                       1688);
                    6. Food Stamp Act of 2008 (7 U.S.C. §2011 et seq.); and
                    7. HHSC’s administrative rules, as set forth in the Texas
                       Administrative Code, to the extent applicable.

                 To ensure compliance with DSHS non-discrimination             policies D SHS
                 contractors must:
                       Have a written policy th at states the agency does not discriminate
                         on the basis of race, color, national origin including LEP, religion,
                         disability, age, or sex;
                       Sign a written assurance as to compliance with applicable federal
                         and state civil rights laws and regulations;
                  Have procedures for notifying the HHSC Civil Rights Office of any
                    program or service-related discrimination allegation or complaint within
                    ten (10) calendar days after receipt of the allegation or complaint.
                    Notice provided pursuant to this section must be directed to:
                                            HHSC Civil Rights Office
                                      701 W. 51st Street, Mail Code W206
                                              Austin, Texas 78751
                                       Phone Toll Free: (888) 388-6332
                                             Phone: (512) 438-4313
                                        TTY Toll Free: (877) 432-7232
                                              Fax: (512) 438-5885
                       Notify all clients and applicants of the            contractors non-
                         discrimination policies and complaint procedures;
                       Ensure that all contractor staff is trained in the agency’s non-
                         discrimination policies and complaint procedures;
Non-
                        Take reasonable ste ps to ensure that L EP persons have
Discrimination
                         meaningful access to its programs and services, and not require a
(continued)
                         client with L EP to use friends or fa mily members as interpr eters.
                         However, a family member or friend may serve as their interpreter
                         at the client ’s request, and the fam ily member or friend do es not
                         compromise the effectiveness of the service or violate client
                         confidentiality

                 The contractor must prominently display in clien t common areas, including
                 lobbies and waiting rooms, front reception d esks and l ocations where
                 clients apply for services, the following three posters:



                                                                                  September 2011
                                                                               SECTION TWO
                                                                     PROGRAM ADMINISTRATION
                                                                                                     5
                       “Know Your Rights” [English] [Spanish]

                        Size: 8.5” x 11” (standard size sheet of paper)
                        Posting Instructions: Post the English and Spanish versions of
                        this poster next to each other Questions: Contact the HHSC Civil
                        Rights Office

                       “Need an Interpreter” [Language Translation] [American Sign
                        Language]

                        Size: 8.5” x 11” (standard size sheet of paper)
                        Posting Instructions: Post the “Language Translation” version
                        and American Sign Language” version next to each other
                        Questions: Contact the HHSC Civil Rights Office

                       Americans with Disabilities Act [English A] [Spanish A]
                        [English B] [Spanish B]

                                Size: 8.5” x 11” or 8.5” x 14”             Posting
                                instructions: Post with other civil rights posters
                                Questions: Contact the HHSC Civil Rights Office

                 The contractor must have available, completed, and signed copies of the
                 Non-Discrimination Policies an d Procedures Survey, ADA/Section 5 04
                 Policies and Procedures, and Limited English Proficiency (LEP) Policies
                 and Procedures Survey prior to any scheduled on-site review by t he
                 Quality Management (QMB) review team.

                       More information about applicable laws and regulations can be
                        found on HHSC Office of Civil Rights Office website at:
                        http://www.hhs.state.tx.us/aboutHHS/CivilRights.shtml.


                       The Non-Discrimination Policie s and P rocedures Survey,
                        ADA/Section 504 Policies an d Procedures Survey, and Limited
                        English Proficiency (LEP) Policies and Procedures Survey and their
                        instructions can be downloaded at the QMB Website at:
                        http://www.dshs.states.tx.us/qmb/contact.shtm.


Termination of   Clients must never be denied services due to an inability to pay.
Services
                 Contractors have the right to terminate se rvices to a client if the client is
                 disruptive, unruly, threatening, or uncooperative to the extent that the client
                 seriously impairs the contractor’s ability to provide services or if the client’s
                 behavior jeopardizes the safety of himself or herself, clinic staff, or other
                 clients. Contractors have the right to terminate services to a client if t    he
                 client is disruptive, unruly, threatening, or unco operative to the extent t hat
                 the client seriously impairs the contr actor’s ability to provide services or if
                 the client’s behavior jeopardizes his or her own safety, clinic staff, or other
                 clients.


                                                                                      September 2011
                                                                                SECTION TWO
                                                                      PROGRAM ADMINISTRATION
                                                                                                      6
                 Any policy related to t ermination of services must be included in            the
                 contractor’s policy and procedures manual.


Resolution of    Contractors must ensure that clients have the opportunity to exp    ress
Complaints       concerns about care received and to further en sure that those complaints
                 are handled in a consistent manner.

                 Contractor’s policy and procedure manuals             must explain the process
                 clients will follow if they are not satisfi ed with the care received or feel they
                 have been discriminate d against or treated ina ppropriately or unfairly. In
                 accordance with PHC rule, 25           TAC §39.10 (relating to Appeals), an
                 applicant or client may appeal a decision according to the procedures
                 outlined in 25 TAC §§1.51 – 1 .55 (relating to DSHS Fair Hearings
                 Procedures). If an aggrieved client requests a hearing, co ntractors shall
                 not terminate services to the client until a final decision is rendered.

                 Any client complaint must be documented in the client’s record.


Client Records   DSHS contractors must have an organized          and secur e client record
Management       system. The contractor must ensure that the r ecord is org anized, readily
                 accessible, and available to the clie nt upon request with a signed release
                 of information. The records must be kep t confidential and secure, as
                 follows:
                       Safeguarded against lost and used by unauthorized persons;
                       Secured by lock when not in use or inaccessible to unauthorize d
                         persons; and
                       Maintained in a se cure environment in the facility as well as during
                         transfer between clinics and in between home and office visits.

                 The written consent of t he client is required for the release of personally
                 identifiable information, except as ma y be necessary to provide services to
                 the client or as required by l      aw, with a ppropriate safeguards for
                 confidentiality. HIV information should be handled according to law.
                 (See: http://www.dshs.state.tx.us/hivstd/policy/laws.shtm).


Client Records   When information is requested, contractors should release only the specific
Management       information requested. Information collected for reporting purposes may be
(continued)      disclosed only in summary, statistically, or in a form that does not identify
                 particular individuals. Upon request, client s transferring to other providers
                 must be provided with a copy or       summary of their record to expedite
                 continuity of care. Electronic records are acceptable as medical records.

                 Contractors, providers, sub-recipients, and subcontractors must maintain
                 for the time period sp ecified by DSHS all records pert aining to client
                 services, contracts, and payments. Record retention requirements are
                 found in 15 TAC §354.1004 (relating to Time Limits for Submitted Medicaid
                 Claims) and 22 TAC 16 5 (relating to Medical Records). Contractors must



                                                                                      September 2011
                                                                               SECTION TWO
                                                                     PROGRAM ADMINISTRATION
                                                                                                     7
                 follow contract provisions and the DSHS Retention Schedule for Medical
                 Records. All records relating to serv        ices must be accessib le for
                 examination at any rea sonable time to representatives of DSHS and as
                 required by law. DSHS guidelines for medical record           retention are
                 available at: http://www.dshs.state.tx.us/records/medicalrec.shtm

                 All medical records and supporting documentation for Title XIX Medicaid
                 services must be maintained in accordance with Medicaid rules as outlined
                 in the 2010 Texas Medicaid Provi der Procedures Manual, Section 1 .4.3
                 (page 1-18).

                 http://www.tmhp.com/TMPPM/2010/Vol1_01_Provider_Enrollment.pdf


Personnel        Contractors must develop and maintain personn el policies and procedures
Policy and       to ensure th at clinical staff are hired , trained, an d evaluated appropriate ly
Procedures       to their job position. Personnel policies and pr ocedures must include job
                 descriptions, a written orientation plan for new staff t o include skills
                 evaluation and/or competencies appropriate for the position,                and
                 performance evaluation process fo r all staff. Job descriptions, including
                 those for contracted personnel, must specify required qualificat ions and
                 licensure. All staff must be appropriately identified with a name badge.

                 Contractors must sho w evidence t hat employees meet all requ            ired
                 qualifications and are provided annual trainin g. Job evaluations sho uld
                 include observation of staff/client interactions during clinical, counseling
                 and educational services.

                 Contractors shall e stablish safeguards to prohibit employees from using
                 their positions for a purpose that constitutes or presents the appearance of
                 personal or organizational conflict of interest or personal gain.

                 Contractors must pro vide medical care services under the supervision,
                 direction, and responsibility of a qualified medical director.

                 Contractors must have a documented plan of or ganized staff development
                 based on an assessment of:


                       Training needs;
                       Quality assurance indicators; and
                       Changing regulations/requirements.

                 Contractors must also include orientation and in-service training for all
                 personnel, including volunteers. T here must be documentation of in itial
                 employee orientation and continuing education.


Facilities and   DSHS contractors are required to maintain a safe environment at all times.
Equipment        Contractors must have written policies and procedures that address
                 hazardous waste, fire safety, and medical equipment.


                                                                                      September 2011
                                                             SECTION TWO
                                                   PROGRAM ADMINISTRATION
                                                                                  8
Hazardous Materials – Contractors must have written policies and
procedures that address:
    The handling, storage, and disposing of hazardous materials and
      waste according to applicable laws and regulations;
    The handling, storage, and disposing of chemical and infectious
      waste including sharps; and
    An orientation and education program for personnel who manage or
      have contact with hazardous materials and waste

Fire Safety – Contractors must have a written fire safety policy that
includes a schedule for testing and maintenance of fire safety equipment.
Evacuation plans for the premises must be clearly posted and visible to all
staff and clients.

Medical Equipment – Contractors must have a written policy and maintain
documentation of the maintenance, testing, and inspection of medical
equipment. Documentation must include:
    Assessments of the clinical and physical risks of equipment through
      inspection, testing and maintenance;
    Reports of any equipment management problems, failures and use
      errors;
    An orientation and education program for personnel who use
      medical equipment; and
    Manufacturer recommendations for care and use of medical
      equipment.

Smoking Ban – Contractors must have written policies that prohibit
smoking in any portion of their indoor facilities. If a contractor subcontracts
with another entity for the provision of health services, the subcontractor
must also comply with this policy.

Disaster Response Plan – Written and oral plans that address how staffs
are to respond to emergency situations (i.e., fires, flooding, power outage,
bomb threats, etc.). A disaster response plan must be in writing, formally
communicated to staff, and kept in the workplace available to employees
for review. For an employer with 10 or fewer employees, the plan may be
communicated orally to employees.

For additional resources on facilities and equipment, you can visit:
http://osha.gov/.




                                                                   September 2011
                                                                         SECTION TWO
                                                               PROGRAM ADMINISTRATION
                                                                                             9

Quality      Organizations that embrace Quality Manage ment (QM) concept s and
Management   methodologies and integrate them into the structure of the organization and
             day-to-day operations discover a very powerful management tool. Quality
             Management programs can vary in structure an d organization and will be
             most effective if they a re individualized to meet the needs of a specif ic
             agency, services and the populations served.

             Contractors are expected to develop quality processes ba sed on the four
             core Quality Manageme nt principles of focusing on: the client, systems
             and processes, measurement and teamwork. Contractors must have a
             Quality Management program individualized to their organizational
             structure and based on the services provided.      The goals of the quality
             program should ensure availability and accessibility of services, and quality
             and continuity of care.

             A Quality Management program mu st be developed and implemented that
             provides for ongoing evaluation of services. Contractors should have a
             comprehensive plan for the internal review, measurement and evaluation of
             services, the analysis of monito    ring data, and the development      of
             strategies for improvement and sustainability. Contractors who subcontract
             for the pro vision of services must also address how quality will be
             evaluated and how compliance with policie s and basic standards will be
             assessed with the subcontracting entities.

             The Quality Manage ment Committee, whose membership consists of key
             leadership of the orga nization, including the Executive Director/CEO and
             the Medical Director, where applicable, annually reviews and approves t he
             quality work plan for the orga      nization. The Quality     Management
             Committee must meet at least quarterly to:
                  Receive reports of monitoring activities;
                  Make decisions based on the analysis of data collected;
                  Determine quality improvement actions to be implemented; and
                  Reassess outcomes and goal achievement.

             Minutes of the discussion and actions taken by the co     mmittee must be
             maintained.

             The quality work plan at a minimum must:
                 Include clinical and administrative standards b y which services will
                   be monitored;
                 Include process for credentialing and peer review of clinicians;
                 Identify individuals re sponsible for implementing monitoring,
                   evaluating and reporting;
                 Establish timelines for quality monitoring activities;
                 Identify tools/forms to be utilized; and
                 Outline reporting to the Quality Management Committee.




                                                                              September 2011
                                                                             SECTION TWO
                                                                   PROGRAM ADMINISTRATION
                                                                                                 10

Quality          Although each organization’s quality program is unique,         the following
Management       activities must be undertaken by all agencies providing client services:
(continued)           On-going eligibility, billing, and cli nical record reviews to assure
                          compliance with program requirements and clinical stan dards of
                          care;
                      Tracking and reporting of adverse outcomes;
                      Client satisfaction surveys;
                      Annual review of facilities to mainta in a safe environment, including
                          an emergency safety plan; and
                      Annual review of policies, clinical protocols and standing delegation
                          orders (SDOs) to ensure they are current.

                 Data from t hese activities must be presented t o the Quality Manage ment
                 Committee. Plans to improve quality should result from the data analysis
                 and reports considered by the committee and should be documented.

                 Information on the operating process of DSHS’s Quality Management
                 Branch as well as policies and review tools can be located at:
                 http://www.dshs.state.tx.us/qmb/default.shtm.




Programmatic Contractor shall provide information and supporting documentation as
Eligibility Desk requested by DSHS to conduct pro grammatic desk reviews to verify client
Reviews          eligibility for PHC Program. Failure to submit requested in formation in a
                 timely manner may re sult in sanctions according to pr ovisions of the
                 contract.       If contractor’s desk reviews   results in a finding     of
                 misappropriation of DSHS PHC c o-payment (co-pay) policy, contra ctor
                 shall reimburse client(s).




                                                                                  September 2011
  SECTION THREE


ELIGIBILITY CRITERIA
 & CLIENT SERVICES
                                                                         SECTION THREE
                                                                    ELIGIBILITY CRITERIA
                                                                                            1



General      For an individual to receive PHC services, three (3) criteria must be met:
Principles
                •   Not eligible for other programs/benefits providing the same services;
                •   Texas resident; and
                •   Gross family income at or below 150% of the adopted Federal
                    Poverty Level (FPL).

             Contractor Responsibilities – The contractor must ensure the eligibility
             process is complete and includes documentation of the following:

                •   Individual/family name, present address, date of birth, and whether
                    the individual/family members are currently eligible for Medicaid or
                    other benefits;
                •   Health insurance policies, if applicable, providing coverage for the
                    individual, spouse, and dependent(s);
                •   Monthly income of individual and spouse; and
                •   Other benefits available to the family or individual. Any specified or
                    other supporting documentation necessary for the contractor to
                    determine eligibility;

             The contractor will:

                •   Use the DSHS Funding Source - Application For Health Care
                    Assistance (Form EF05-13229); DSHS Funding Source – Worksheet
                    (Form EF05-13227); and verification/documentation procedures
                    established by DSHS or completion of a c omparable paper or
                    electronic screening and eligibility tool that has the required DSHS
                    information for determining eligibility;
                •   Assist the applicant with accurately completing the application for
                    screening and eligibility determination purposes;
                •   Ensure that the verification the individual provides is sufficient to
                    make an eligibility decision. Request for Information (Form 104) may
                    be used to assist applicants with requested verification requirements;
                •   Document oral designations of any additional contacts;
                •   Determine eligibility for PHC services based on the three (3) eligibility
                    criteria;
                •   Provide the eligible individual information regarding the services
                    he/she is entitled to receive and his/her rights and responsibilities;
                •   Advise the client of his/her responsibility to report changes; and
                •   Determine the effect reported changes have on the client’s eligibility
                    by re-screening and completing the eligibility determination process.




                                                                                 PHC 10-1
                                                                            September 2010
                                                                               SECTION THREE
                                                                          ELIGIBILITY CRITERIA
                                                                                                   2

General         The contractor shall allow the individual an opportunity to resolve any
Principles      discrepancy by providing documentary evidence or by designating a suitable
(continued)     contact to verify information. If the individual fails or refuses to do so,
                eligibility can be deni ed. D ocument this information on t he DSHS Funding
                Source - Worksheet.

                Special circumstances may occur in the disclosure of information,
                documentation of pertinent facts, or events surrounding the client’s
                application for services that make decisions and judgments by the contractor
                staff necessary. These circumstances should be doc umented in the case
                record on the DSHS Funding Source - Worksheet.

                Applicant’s Responsibility –

                   •   Complete the DSHS Funding Source - Application For Health Care
                       Assistance (Form EF05-13229) or request assistance for completion;
                   •   Provide requested verification by the contractor. Failure to provide all
                       required information will result in denial of eligibility. If verification is
                       not available or is insufficient to determine eligibility, contractor staff
                       should ask the individual to designate a contact person to provide the
                       information.

                Client’s Responsibility for Reporting Changes – A client must report
                changes in the following area: income, family composition, residence,
                address, employment, types of medical insurance coverage, and r eceipt of
                Medicaid and/or third-party coverage benefits. The client may report
                changes by mail, telephone, in-person, or through someone acting on the
                individual’s behalf. Changes must be reported no later than 14 days after the
                client is aware of the change. If changes result in the client no l onger
                meeting eligibility criteria, the individual is denied continued services. By
                signing the required forms, the individual attests to the truth of the
                information provided.


Screening &     Clients Screened Potentially Eligible for Other Benefits – Contractors
Eligibility     must work to ensure that individuals seeking PHC covered services use
Determination   other programs or benefits first. I f individuals are determined potentially
                eligible for other benefits, contractors must refer them to the specific
                programs and assist them in completing the eligibility determination process.
                It is possible that a family will be referred to several programs as a result of
                the eligibility determination process. P rograms/benefits that must be us ed
                first include:

                   •   Private/Employer Insurance;
                   •   Medicare;
                   •   Medicaid;
                   •   TRICARE;
                   •   County Indigent Health Care;
                   •   Children with Special Health Care Needs;


                                                                                  September 2011
                                                                             SECTION THREE
                                                                        ELIGIBILITY CRITERIA
                                                                                                3
Screening &
Eligibility        •   CHIP (other than family planning services);
Determination      •   CHIP Perinatal;
(continued)        •   Title V, Title X, Title XIX (including WHP), and Title XX Family
                       Planning;
                   •   Breast and Cervical Cancer Services;
                   •   Women’s Health Program;
                   •   Worker’s Compensation;
                   •   Veteran’s Administration Benefits; or
                   •   Other comprehensive healthcare plans.

                Individuals must be screened for potential Medicaid, CHIP, or other programs
                by using the DSHS Funding Source – Application For Health Care
                Assistance (Form EF05-13229) or a comparable paper or electronic
                screening and el igibility tool that has the required DSHS information and
                applicant’s signature for determining eligibility. A copy of the Application For
                Health Care Assistance must be maintained in the medical record.

                For PHC purposes, contractors may use the Health and Human Services
                Commission’s         (HHSC)       Your      Texas      Benefits    website
                (www.yourtexasbenefits.com) to assist in the screening of client eligibility.
                The website offers access to information on H HSC benefits including
                Medicaid, Supplemental Nutrition Assistance Program (SNAP), Temporary
                Assistance for Needy Families (TANF), Children’s Health Insurance
                (CHIP), and nursing home care and other services for people who are elderly
                or have disabilities. The use of this system may replace the DSHS Funding
                Source – Worksheet (Form EF05-13227), but can not replace the DSHS
                Funding Source – Application (Form EF 05-13299). More information about
                HHSC benefits can also be obtained by calling 2-1-1.

                The applicant is responsible for completing page one of his/her own DSHS
                Funding Source – Application For Health Care Assistance (Form EF05-
                13229). If the applicant is incompetent, or incapacitated, someone acting
                responsibly for the client (a representative) may represent the applicant in
                the application and the review process, including signing and dating the Form
                EF05-13229 on t he applicant’s behalf. This representative must be
                knowledgeable about the applicant and his household. A copy of this form
                and instructions can be found in the Forms Section of the Policy and
                Procedures Manual. I f assistance is needed i n completing the form, the
                contractor shall provide knowledgeable staff to assist. It is acceptable to fill
                out the form once and photocopy the form for the number of family members
                needed. The family member name listed under the family composition chart
                on question 1 can be (highlighted/circled) to indicate the intended client
                record in which it shall be filed. If the applicant is married and his/her spouse
                is a hous ehold member, the spouse must also sign and da te the DSHS
                Funding Source – Application For Health Care Assistance (Form EF05-
                13229). If confidentiality of services is a concern, separate forms for
                spouses may be completed. The signature of anyone assisting in completion
                of the form is required as well. The form is filed in the client record.


                                                                                September 2011
                                                                             SECTION THREE
                                                                        ELIGIBILITY CRITERIA
                                                                                                4
Screening &     Family Composition/Household
Eligibility
Determination   Establishing family composition/household is an i mportant step in the
(continued)     eligibility process. A ssessment of income eligibility relies on an ac curate
                count of family members. A family is defined as a person living alone or a
                group of two or more persons related by birth, marriage (including common-
                law), or adoption, which reside together and a re legally responsible for the
                support of the other person. Unborn children are also included in family size.

                Children and Family Composition – A child must be under 18 years of age to
                be counted as part of a family. Eligibility will end on the last day of the month
                the child become 18 years of age unless the child is:

                   •   A full-time high school student as defined by the school, attends an
                       accredited GED class, or regularly attends vocational or technical
                       training in place of high school, and

                   •   Expected to graduate from one of the above before or during the
                       month of his/her 19th birthday.

                A child who is 18 years of age or older and r esides with his/her
                parent(s)/guardian(s), but is not currently attending high school is considered
                a family of one.

                A child may be c onsidered part of a family when living with relatives other
                than natural parents if documentation can be pr ovided that verifies the
                relationship. A cceptable documents include birth certificates or other legal
                documents that demonstrate the relationship between the caretaker and the
                child.   If no biological relationship exists between the caretaker or
                documentation is not provided to verify biological relationship:

                   •   The child becomes a separate PHC household;
                   •   The situation must be explained on the worksheet; and
                   •   Caretaker may apply for PHC benefits on child’s behalf.

                Verification/Documentation of Family Composition – To verify family
                relationships, one of the following items may be provided, if questionable:
                    • Birth certificate;
                    • Baptismal certificate;
                    • School records; or
                    • Other documents or proof of family relationship determined valid by
                        the contractor to establish the dependency of the family member
                        upon the client or head of household.

                Family members who receive other health care benefits are included in the
                family count. T he contractor has discretion to document special
                circumstances in the calculation of family composition. Additionally, if a
                separate family group is established within the household based on the
                documentation gathered, document the basis used for determining separate
                households on the DSHS Worksheet (Form EF05-13227).


                                                                                September 2011
                                                                            SECTION THREE
                                                                       ELIGIBILITY CRITERIA
                                                                                                5
Screening &
Eligibility     Residency
Determination
(continued)     To be eligible for PHC, an individual must be p hysically present within the
                geographic boundaries of Texas and:
                   • Has the intent to remain within the state, whether permanently or for
                      an indefinite period;
                   • Does not claim residency in any other state or country; and/or
                   • Is less than 18 y ears of age and hi s/her parent, managing
                      conservator, or guardian is a resident of Texas.

                There is no requirement regarding the amount of time an individual must live
                in Texas to establish residency for the purpose of PHC eligibility.

                Although the following individuals may reside in Texas, they are not
                considered Texas residents for the purpose of receiving PHC services and
                are considered ineligible:
                    • Inmates of correctional facilities;
                    • Residents of state or federal schools; and
                    • Patients in federal institutions or state psychiatric hospitals.

                Verification/Documentation of Residency – Document proof of residency
                provided by the client on the DSHS Funding Source – Worksheet
                and explain why residency is questionable, if necessary. For verification of
                residency, one of the following items shall be provided:

                   •   Valid Texas Drivers License;
                   •   Current voter registration;
                   •   Rent or utility receipts for one month prior to the month of application;
                   •   Motor vehicle registration;
                   •   School records;
                   •   Medical cards or other similar benefit cards;
                   •   Property tax receipt;
                   •   Mail addressed to the applicant, his/her spouse, or children if they live
                       together; or
                   •   Other documents considered valid by the contractor.

                If none of the listed items are available, residence may be verified through:
                    • Observance of personal effects and living arrangement, or
                    • Statement from landlords, neighbors, other reliable sources.

                Temporary Absences from State – Individuals do not lose their residency
                status because of temporary absences from the state. Fo r example, a
                migrant or seasonal worker may travel during certain times of the year but
                maintains a home in Texas and returns to that home after these temporary
                absences.      If a family is otherwise eligible, but residence is in
                question/dispute, the household is entitled to services until factual
                information regarding residency change proves otherwise.




                                                                               September 2011
                                                                              SECTION THREE
                                                                         ELIGIBILITY CRITERIA
                                                                                                 6

Screening &     Income
Eligibility
Determination   To be eligible for PHC, clients must have a gross family income at or below
(continued)     150% FPL. The table below details sources of income that contribute to the
                calculation of gross family income as well as income that is exempt from
                being counted.

                       Types of Income                          Countable     Exempt

                       Adoption Payments                                      X
                       Cash Gifts and Contributions*            X
                       Child Support Payments*                  X
                       Child's Earned Income                                  X
                       Crime Victim's Compensation *                          X
                       Disability Insurance Benefits/SSDI*      X
                       Dividends, Interest, and Royalties*      X
                       Educational Assistance                                 X
                       Energy Assistance                                      X
                       Foster Care Payment                                    X
                       In-kind Income                                         X
                       Job Training                                           X
                       Loans (Non-educational)*                 X
                       Lump-Sum Payments*                       X             X
                       Military Pay*                            X
                       Mineral Rights*                          X
                       Pensions and Annuities*                  X
                       Reimbursements*                          X
                       RSDI /SSDI/Social Security Payments*     X
                       Self-Employment Income*                  X
                       SSI Payments                                           X
                       TANF                                                   X
                       Unemployment Compensation*               X
                       Veteran's Administration*                X              X
                       Wages and Salaries, Commissions*         X
                       Worker's Compensation*                   X

                *Explanation of countable income provided below


                Cash Gifts and Contributions – Count unless they are made by a private, non-
                profit organization on the basis of need; and total $300 or less per household in
                a federal fiscal quarter. The federal fiscal quarters are January – March, April –
                June, July – September, and October –December. If these contributions exceed
                $300 in a quarter, count the excess amount as income in the month received.

                Exempt any cash contribution for common household expenses, such as food,
                rent, utilities, and items for home maintenance, if it is received from a non-
                certified household member who:



                                                                                   September 2011
                                                                             SECTION THREE
                                                                        ELIGIBILITY CRITERIA
                                                                                                7

Screening &        •   Lives in the home with the certified household member,
Eligibility        •   Shares household expenses with the certified household member, and
Determination      •   No landlord/tenant relationship exists.
(continued)
                Child Support Payments – Count income after deducting $75 from the total
                monthly child support payments the household receives.

                Disability Insurance Payments/SSDI – Countable. Social Security Disability
                Insurance is a payroll tax-funded, federal insurance program of the Social
                Security Administration. Medical condition prohibits work for one year or results
                in death.

                Dividends, Interest and Royalties – Countable. Exception: Exempt dividends
                from insurance policies as income.

                Count royalties, minus any amount deducted for production expenses and
                severance taxes.

                In-Kind Income – Exempt. A n in-kind contribution is any gain or benefit to a
                person that is not in the form of money/check payable directly to the household,
                such as clothing, public housing, or food.

                Loans (Non-educational) – Count as income unless there is an understanding
                that the money will be repaid and the person can reasonably explain how he/she
                will repay it.

                Lump-Sum Payments – Count as income in the month received if the person
                receives it or expects to receive it more often than once a year.

                Exempt lump sums received once a y ear or less, unless specifically listed as
                income.

                Military Pay- Count military pay and allowances for housing, food, base pay,
                and flight pay, minus pay withheld to fund education under the G.I. Bill.

                Mineral Rights – Countable. A payment received from the excavation of
                minerals such as oil, natural gas, coal, gold, copper, iron, limestone, gypsum,
                sand, gravel, etc.

                Pensions and Annuities – Countable. A pension is any benefit derived
                from former employment, such as retirement benefits or disability pensions.

                Reimbursements – Countable, minus the actual expenses. E xempt a
                reimbursement for future expenses only if the household plans to use it as
                intended.

                RSDI/SSDI/Social Security Payments – Count the Retirement, Survivors,
                and Disability Insurance (RSDI) benefit amount including the deduction for
                the Medicare premium, minus any amount that is being recouped for a prior
                RSDI overpayment.


                                                                                September 2011
                                                                            SECTION THREE
                                                                       ELIGIBILITY CRITERIA
                                                                                               8

Screening &     Self-Employment Income – Count total gross earned, minus the allowable
Eligibility     costs of producing the self-employment income.
Determination
(continued)     SSI Payments – Exempt Supplemental Security Income (SSI) benefits.

                Terminated Employment – Count terminated income in the month received.
                Use actual income and do not use conversion factors if terminated income is
                less than a full month’s income. Income is terminated if it will not be received
                in the next usual payment cycle.

                Unemployment Compensation Payments – Count the gross benefit less
                any amount being recouped for a UIB overpayment.

                VA Payments – Count the gross Veterans Administration (VA) payment,
                minus any amount being recouped for a VA overpayment. Exempt VA
                special needs payments, such as annual clothing allowances or monthly
                payments for an attendant for disabled veterans.

                Wages, Salaries, Tips and Commissions – Count the actual (not taxable)
                gross amount.

                Worker’s Compensation – Count the gross payment, minus any amount
                being recouped for a pr ior worker’s compensation overpayment or paid for
                attorney’s fees. NOTE: The Texas Workforce Commission (TWC) or a court
                sets the amount of the attorney’s fee to be paid.

                Verification/Documentation of Income – Verification and documentation of
                income must be pr ovided to complete the DSHS Funding Source -
                Worksheet. D eclarations of “unknown” will not be ac cepted as
                representations of required facts and documentation.           Incomplete or
                inadequately documented eligibility determination will result in limitations in
                the provision of funded services. To verify income, one of the following must
                be provided: a minimum of three (3) consecutive, current pay periods or one
                month’s pay only if paid same gross amount on a monthly basis, unless
                special circumstances are noted on the DSHS Funding Source - Worksheet:
                    • Copy(ies) of the most recent paycheck stub/monthly earning
                        statement(s);
                    • Employer’s written verification of gross monthly income or the
                        Employment Verification Form (Form 128);
                    • Award letters;
                    • Domestic relation printout of child support payments;
                    • Letter of support
                    • Unemployment benefits statement or letter from the Texas Workforce
                        Commission;
                    • Award letters, court orders, or public decrees to verify support
                        payments ; or
                    • Notes for cash contributions.



                                                                               September 2011
                                                                          SECTION THREE
                                                                     ELIGIBILITY CRITERIA
                                                                                            9

Screening &     If all attempts to verify income are unsuccessful because the employer/payer
Eligibility     fails or refuses to provide information or threatens continued employment,
Determination   and no other proof can be found, staff may determine an amount to use on
(continued)     the form based on t he best available information and doc ument the
                determined income on the DSHS Funding Source – Worksheet.

                Income Determination Procedure

                   •   Count income already received and any income the household
                       expects to receive. When an individual has not yet received income
                       for new employment, use the best estimate of the amount to be
                       received. I f telephone verification regarding new or terminated
                       employment is made, it must be documented by the contractor on the
                       DSHS Funding Source – Worksheet (Form EF05-13227).

                   •   Count terminated income in the month received. Use actual income
                       and do not use conversion factors if terminated income is less than a
                       full month’s income.

                   •   Use at least three consecutive, current pay periods to calculate
                       projected monthly income. I f client is paid one t ime per month and
                       receives the same gross pay each month, then one pay period will
                       suffice.

                   •   If actual or projected income is not received monthly, convert it to a
                       monthly amount using one of the following methods:

                          o   Weekly income x 4.33;
                          o   Every two weeks x 2.17; or
                          o   Twice a month x 2.0.

                   •   Dependent childcare expenses shall be deducted from total income in
                       determining eligibility. Allowable deductions are actual expenses up
                       to $200 pe r child per month for children under age 2 and $175 pe r
                       child per month for children age 2 to 12 or age 2 to 18 if child is
                       disabled.

                   •   Legally obligated child support payments made by a member of the
                       household group shall also be deducted. Payments made weekly,
                       every two weeks or twice a m onth must be c onverted to a m onthly
                       amount by using one of the above listed conversion factors.

                Self-Employment Income – If an applicant earns self-employment income,
                it must be added to any income received from other sources.

                   •   Annualize self-employment income that is intended for an individual
                       or family’s annual support, regardless of how frequently the income is
                       received.




                                                                             September 2011
                                                                          SECTION THREE
                                                                     ELIGIBILITY CRITERIA
                                                                                           10

Screening &     Determine the costs of producing self-employment income by accepting the
Eligibility     deductions listed on the 1040 U.S. Individual Income Tax Return statement
Determination   or by allowing the following deductions:
(continued)                 o Capital asset improvements;
                            o Capital asset purchases, such as real property, equipment,
                                machinery and ot her durable goods, i.e., items expected to
                                last at least 12 months;
                            o Fuel;
                            o Identifiable costs of seed and fertilizer;
                            o Insurance premiums;
                            o Interest from business loans on income-producing property;
                            o Labor;
                            o Linen service;
                            o Payments of the principal of loans for income-producing
                                property;
                            o Property taxes;
                            o Raw materials;
                            o Rent;
                            o Repairs that maintain income-producing property;
                            o Sales tax;
                            o Stock;
                            o Supplies;
                            o Transportation costs. The person may choose to use 50.0
                                cents per mile instead of keeping track of individual
                                transportation expenses. Do not allow travel to and from the
                                place of business, and
                            o Utilities.

                       NOTE: If the applicant conducts a self-employment business in his
                       home, consider the cost of the home (rent, mortgage, utilities) as
                       shelter costs, not business expenses, unless these costs can be
                       identified as necessary for the business separately.

                   •   If the self-employment income is only intended to support the
                       individual or family for part of the year, average the income over the
                       number of months it is intended to cover.

                   •   If the individual has had self-employment income for the past year,
                       use the income figures from the previous year’s business records or
                       tax forms.

                   •   If current income is substantially different from income the previous
                       year, use more current information, such as updated business
                       ledgers or daybooks. R emember to deduct predictable business
                       expenses.

                   •   If the individual or family has not had self-employment income for the
                       past year, average the income over the period of time the business
                       has been in operation and project the income for one year.

                                                                             September 2011
                                                                            SECTION THREE
                                                                       ELIGIBILITY CRITERIA
                                                                                            11

Screening &        •   If the business is newly established and there is insufficient
Eligibility            information to make a r easonable projection, calculate the income
Determination          based on the best available estimate and follow-up at a later date.
(continued)
                   •   A signed statement from individuals who are self-employed and have
                       no documentation of their income will be accepted for a period of six
                       months. P HC coverage cannot be ex tended on s ubsequent
                       applications without formal verification and do cumentation of self-
                       employment income.

                Seasonal Employment – Include the total income for the months worked in
                the overall calculation of income. The total gross income for the year can be
                verified by a letter from the individual’s employer, if possible.

                Statements of Support – Unless the person providing the support to the
                individual is present during the interview and has acceptable documentation
                of identity, a statement of support will be required. The Statement of Support
                is used to document income when no supporting documentation is available
                or when income is irregular. If questionable, the contractor may document
                proof of identification such as a Texas Drivers License, Social Security card,
                or a birth certificate of the supporter.

                Eligibility Determination

                The contractor must consider the information provided by the client and
                document the basis for the eligibility decision on the DSHS Funding Source –
                Worksheet (Form EF05-13227). T he client must sign the Statement of
                Applicant’s Rights and Responsibilities (Form 101) to complete the eligibility
                determination.

                This form does not have to be s igned again unless there is a br eak in
                services for two years or longer. It is required that after determining
                eligibility, the provider stating that either the family or individual is:

                   •   Eligible
                       o The individual/family is eligible for assistance;
                       o The date eligibility begins and expires; and
                       o The services the individual/family is entitled to receive.

                   •   Ineligible
                       o The individual/family is denied eligibility;
                       o The reason the application was denied;
                       o The effective date of denial;
                       o The individual’s right to appeal; and
                       o The appropriate referrals to alternative agencies/programs for
                           services.




                                                                               September 2011
                                                                            SECTION THREE
                                                                       ELIGIBILITY CRITERIA
                                                                                              12

Screening &     Appeal of Eligibility Determination – Individuals and families can appeal to
Eligibility     DSHS regarding the eligibility determination for PHC if they feel that
Determination   information was incorrectly considered. A pplicants may submit additional
(continued)     information to establish eligibility, or repeat the application process.

                Date Eligibility Begins – An individual/family is entitled to services
                beginning with the date the completed application was submitted.

                Presumptive Eligibility – Households, who have not had a final eligibility
                determination and a member in the household presents with an immediate
                medical need, may receive PHC funded services on a presumptive eligibility
                basis during the time that eligibility for services is pending. P resumptive
                eligibility is effective for 90 days from the date the member of the household
                is first seen by the medical provider. The household shall be enrolled on a
                presumptive eligibility basis only once in a 12-month period. If a medical
                condition makes eligibility determination impossible and t he applicant’s
                spouse (if applicable) is not present to sign and date the DSHS Funding
                Source – Application For Health Care Assistance (Form EF05-13229),
                provide immediate treatment and s end a copy of the application with the
                client for spouse’s signature. The Presumptive Eligibility Form (102) is not to
                be used in lieu of the DSHS Funding Source – Application For Health Care
                Assistance (Form EF05-13229). An appointment to complete the process
                should be made at the first possible opportunity. If the household has
                applied for another program, the contractor is responsible for updating the
                eligibility status on a timely basis.

                Documented proof of eligibility within the other funding sources is required. If
                emergency services are needed i mmediately and ar e not provided by
                another program, services shall be provided during this 90-day period. If a
                household member becomes Medicaid eligible, the services must be billed to
                Medicaid under the 90-days prior provision.

                PHC emphasizes the importance of prevention and early intervention. The
                goal of PHC is for clients to be part of the health care system and not rely on
                episodic, acute care. An applicant’s medical needs shall be met quickly and
                appropriately using whatever resources are available.

                Two exceptions to using other benefits in place of PHC include:

                   •   If the benefits were created by the establishment of a city or county
                       hospital, a joint city-county hospital, a c ounty hospital authority, a
                       hospital district, or by the facilities of a publ icly supported medical
                       school. Benefits created by any of these entities would not disqualify
                       individuals from using PHC services.

                   •   Contractors are not expected to refer clients to the County Indigent
                       Health Care Program (CIHCP) if the county of residence is covered
                       by a hospital district to provide CIHCP services, or the client does not
                       meet the county’s eligibility criteria for the program.



                                                                               September 2011
                                                                              SECTION THREE
                                                                         ELIGIBILITY CRITERIA
                                                                                                13

Screening &     Individuals potentially eligible for Medicaid or CHIP should be referred to the
Eligibility     Your Texas Benefits website (www.yourtexasbenefits.com) or 2-1-1 for
Determination   comprehensive Medicaid or CHIP eligibility determination.
(continued)
                Clients who are determined eligible or potentially eligible for CHIP may also
                be eligible for PHC-funded services during the waiting period until CHIP
                coverage begins. Contractors are allowed to continue providing PHC-funded
                services after the initial 90-day period only if the client has applied for CHIP,
                is waiting on approval, and until the date CHIP enrollment is effective. A
                copy of the CHIP eligibility card showing when CHIP coverage will begin
                must be kept in the clients’ medical records.

                Individuals who are determined potentially eligible for another benefit by the
                DSHS Funding Source – Application for Health Care Assistance (Form EF05-
                13229), but fail to fully complete the required application process for the
                benefit, will not be e ligible to receive PHC-funded services beyond those
                services delivered during the 90-day presumptive eligibility period. If within
                90 days a client fails to complete the eligibility determination process for
                another benefit, the contractor may bill PHC for the services delivered during
                the 90-day period only. Contractors should make clients aware that failing or
                refusing to complete the appropriate eligibility determination processes may
                result in their determination as self-pay clients.

                Supplemental Benefits – In some cases, individuals receiving benefits from
                other sources such as Medicaid, Medicare, CHIP, Title V, Title X, and Title
                XX may be eligible for partial PHC coverage. This coverage is limited to
                services provided by PHC but not covered by other sources. Whenever
                federal, state, private, or other benefits are available for payment of services
                for clients, no PHC funds shall be used to pay for such care. An example of
                a client receiving supplemental benefits would be a c ontractor providing
                health education services to a Medicaid eligible individual since Medicaid
                does not provide health education services.               The contractor must
                communicate to the client that supplemental services are limited scope.

                Annual Re-certification – The contractor will determine the system used to
                track clients’ status and renewal eligibility. Eligibility determination using the
                DSHS Funding Source – Application for Health Care Assistance (Form
                EF05-13229) form is required for all clients. Eligibility services must be re-
                determined for each individual/family every 12 months.

                At least 30 days prior to the anniversary date of their original eligibility date,
                client should be notified that they must renew eligibility by the anniversary
                date or lose their benefits until they are re-certified by the program. If
                renewal has not been c ompleted by the anniversary date, the
                individual/family record should be removed from active status and placed in
                the inactive files. The individual family should be notified of the status
                change. A client can be a ne w client only once. R egardless of the time
                lapse between the initial application and t he renewal application, former
                clients will not be classified as new.


                                                                                 September 2011
                                                                             SECTION THREE
                                                                        ELIGIBILITY CRITERIA
                                                                                               14
Screening &     Contractors should mail out notices, either postcards or letters, requesting
Eligibility     that the individual or family representative come to the office for re-
Determination   certification. A contractor may include a new application in the letter and ask
(continued)     the individual to return with documentation.

                If an actual interview is chosen, appointment times may be given to prevent
                long waiting periods.

                For each record being renewed, whether in person or by mail, the eligibility
                provider staff shall complete a new DSHS Funding Source – Application for
                Health Care Assistance (Form EF05-13229) using updated information
                provided by the client. Sending a Notice of Eligibility is required to inform the
                individual/family of continued eligibility. The contractor shall assist clients
                who request help in completing forms or providing documentation.


Co-pay/Fees     PHC contractors may assess a fee for services (co-pay) from PHC clients
                whose family income is at or below 150% FPL. Client co-pays may be the
                lesser of $40 or 25% of the Medicaid reimbursement rate. The contractor
                must waive the fee if a client self-declares an inability to pay. No PHC client
                shall be denied services based on an inability to pay. Client co-pays must be
                reported as program income on the monthly State Purchase Voucher (Form
                B-13) and the quarterly Financial Status Report (FSR or Form 269a).
                Example: CPT Code – 99213 = $33.95
                           CPT Code – 80053 = $14.53
                           CPT Code – 80061 = $18.42
                                                  $66.90 x 25% = $16.72 (client co-pay/fee)

Other Fees      Clients shall not be charged administrative fees for items such as processing
                and/or transfer of medical records, copies of immunization records, etc.

                Contractors are allowed to bill clients for services outside the scope of PHC
                allowable services, if the service is provided at the client’s request, and the
                client is made aware of his/her responsibility for paying for the charges.


Continuation    Contractors who have expended their awarded PHC funds are required to
of Services     continue to serve their existing PHC eligible clients.

                If other funding sources are used to provide PHC services, the funds must be
                reported as non-DSHS funds on the monthly State Purchase Voucher (Form
                B-13) and the quarterly Financial Status Report (FSR or Form 269a).




                                                                                September 2011
   SECTION FOUR


CLINICAL INFORMATION
                                                                          SECTION FOUR
                                                                  CLINICAL INFORMATION
                                                                                            1


Clinical   General Informed Consent
Informed
Consent    Contractors must obtain the patient’s written, informed, voluntary general
           consent to receive services prior to receiving any clinical services. A
           general informed consent explains the types of services provided and how
           client/patient information may be shared with other entities for
           reimbursement or reporting purposes. If there is a period of time of three
           years or more during which a pat ient does not receive services a ne w
           general consent must be signed prior to reinitiating delivery of services.

           Consent information must be effectively communicated to every patient in a
           manner that is understandable by that patient and allows her/him to
           participate and make sound decisions regarding her/his own medical care
           in compliance with Limited English Proficiency regulations and addressing
           any disabilities that impair communication. Only the patient may consent.
           For situations when the patient is legally unable to consent (e.g., a minor or
           an individual with development disability), a parent, legal guardian or
           caregiver must consent. Consent must never be obtained in a manner that
           could be perceived as coercive.

           In addition, as described below, the contractor must obtain the informed
           consent of the patient for procedures as required by the Texas Medical
           Disclosure Panel. DSHS contractors should consult a qualified attorney to
           determine the appropriateness of the consent forms utilized by their health
           care agency.

           Method Specific Consent

           The method specific consent and/or the patient health record must
           document that the patient has received and under stands information
           concerning the method effectiveness, appropriate use, benefits, potential
           side effects and complications, alternatives and discontinuation issues.

           Procedure Specific Consents

           Sterilization Procedures – There are two consent forms required for
           sterilization procedures: t he Sterilization Consent Form and the Texas
           Medical Disclosure Panel Consent.

           The Sterilization Consent Form – This sterilization consent form is
           provided in the Texas Medicaid Provider Procedures Manual and i s the
           only acceptable consent form for sterilizations funded by regular Medicaid
           (Title XIX), the Women’s Health Program, Title V, Title X, or Title XX. An
           electronic copy may be found on the Texas Medicaid Healthcare
           Partnership website: http://www.tmhp.com/default.aspx.     The federally
           mandated consent form is necessary for both abdominal and transcervical
           sterilization procedures in women and vasectomy in men.




                                                                             September 2011
                                                                             SECTION FOUR
                                                                     CLINICAL INFORMATION
                                                                                              2


Clinical      In brief, the individual to be sterilized must:
Informed          • Be at least 21 years old at the time the consent is obtained;
Consent           • Be mentally competent;
(continued)       • Voluntarily give his or her informed consent;
                  • Sign the consent form at least 30 days but not more than 180* days
                       prior to the sterilization procedure; and
                  • May choose a witness to be present when the consent is obtained.

              *An individual may consent to be sterilized at the time of premature delivery
              or emergency abdominal surgery, if at least 72 hours have passed after he
              or she gave informed consent to sterilization. In the case of premature
              delivery, the informed consent must have been given at least 30 day s
              before the expected date of delivery.

              The consent form must be signed and dated by:
                 • The individual to be sterilized;
                 • The interpreter, if one is provided;
                 • The person who obtains the consent;
                 • The physician who will perform the sterilization procedure

              Informed consent may not be obtained while the individual to be sterilized
              is:
                  • In labor or childbirth;
                  • Seeking to obtain or obtaining an abortion; or
                  • Under the influence of alcohol or other substances that affect the
                     individual’s state of awareness.

              Texas Medical Disclosure Panel Consent

              The Texas Medical Disclosure Panel (TMDP) was established by the
              Texas Legislature to determine which risks and hazards related to medical
              care and surgical procedures must be disclosed by health care providers or
              physicians to their patients or persons authorized to consent for their
              patients, and to establish the general form and substance of such
              disclosure. TMDP has developed a List A (informed consent requiring full
              and specific disclosure) and a Li st B (informed consent not requiring
              specific disclosures) for certain procedures. More information about the
              TMDP can be found at: http://www.dshs.state.tx.us/hfp/tmdp.shtm

              List A procedures can be found at the following Texas Administrative Code
              link:
              http://info.sos.state.tx.us/pls/pub/readtac$ext.ViewTAC?tac_view=4&ti=25&
              pt=7&ch=601&rl=Y.

              With regard to Tubal Sterilization and V asectomy, List A procedures, the
              TMDP required Disclosure and Consent Form for contractors who




                                                                               September 2011
                                                                             SECTION FOUR
                                                                     CLINICAL INFORMATION
                                                                                              3

              directly perform the procedure can be found at:
Clinical      http://info.sos.state.tx.us/fids/200504268-1.html This consent is in addition
Informed      to the Sterilization Consent Form noted on the previous page.
Consent
(continued)   The required disclosures for Tubal Sterilization are:
                     (A) Injury to the bowel and/or bladder;
                     (B) Sterility;
                     (C) Failure to obtain fertility (if applicable);
                     (D) Failure to obtain sterility (if applicable); and
                     (E) Loss of ovarian functions or hormone production from
                         ovary(ies).

              The required disclosures for Vasectomy are:
                     (A) Loss of testicle; and
                     (B) Failure to produce permanent sterility.

              For all other procedures not listed on List A, the physician must disclose,
              through a procedure specific consent, all risks that a reasonable patient
              would want to know about. This includes all risks that are inherent to the
              procedure (one which exists in and is inseparable form the procedure itself)
              and that are material (could influence a reasonable person in making a
              decision whether or not to consent to the procedure).

              Parental Consent for Services Provided to Minors

              The general rule is that parents must consent for minors (Family Code
              §151.001). A minor is defined as a person less than 18 years of age who
              has never been married. However there are certain circumstances under
              which a minor may consent for her/his own treatment. R equirements for
              parental consent for provision of family planning services to minors vary
              according to the funding source subsidizing the services. The department
              and providers may provide family planning services, including prescription
              drugs, without the consent of the minor’s parent, managing conservator, or
              guardian only as authorized by Chapter 32 of the Texas Family Code or by
              federal law or regulations.

              Title X projects may not require consent of parents or guardians for the
              provision of services to minors. Nor can the project notify parents or
              guardians before or after a minor has requested and received Title X family
              planning services (see Table at end of Chapter). When parental consent is
              required, the parent must sign both the general consent for treatment and
              the method specific consent for prescription birth consent.




                                                                                September 2011
                                                                            SECTION FOUR
                                                                    CLINICAL INFORMATION
                                                                                             4

              There are instances in which a minor may consent to his/her own medical,
Clinical      dental, psychological and surgical treatment by a l icensed physician or
Informed      dentist if the minor:
Consent
(continued)      •   Is on active duty with the armed services;
                 •   Is at least 16 years old, living apart from a parent or guardian and
                     managing his or her own financial affairs. You do not have to
                     provide the child is emancipated if the minor so declares in writing;
                 •   Is consenting to diagnosis and treatment of an infectious,
                     contagious, or communicable disease required to be reported to the
                     local health officer or the Department of State Health Services;
                 •   Consents to examination and treatment for drug or chemical
                     addiction , dependency or any other condition directly related to
                     drug or chemical use;
                 •   Is unmarried and pr egnant and s eeking treatment related to the
                     pregnancy, unless it’s an abortion;
                 •   Has custody of his/her biological child and al so consents to the
                     child’s medical, dental psychological or surgical treatment of the
                     child;
                 •   Is seeking a diagnosis or treatment for a sexually transmitted
                     disease, including HIV;
                 •   Is seeking counseling for chemical dependency or addiction, suicide
                     prevention or sexual, physical or emotional abuse.


              The Texas Family Code, Chapter 32, may be f ound at the following
              website: http://www.statutes.legis.state.tx.us/?link=FA.

              Consent for HIV Tests

              Texas Health and Safety Code §81.105 and §81.106 is as follows:

              §81.105. Informed Consent
                 a) Except as otherwise provided by law, a person may not perform a
                    test designed to identify HIV or its antigen or antibody without first
                    obtaining the informed consent of the person to be test.
                 b) Consent need not be written if there is documentation in the
                    medical record that the test has been ex plained and t he consent
                    has been obtained.

              §81.106 General Consent
                 a) A person who has signed a general consent form for the
                    performance of medical tests or procedures is not required to also
                    sign or be presented with a specific consent form relating to medical
                    test or procedures to determine HIV infection, antibodies to HIV, or
                    infection with any other probable causative agent of AIDS that will
                    be performed on the person during the time in which the general
                    consent form is in effect.



                                                                              September 2011
                                                                             SECTION FOUR
                                                                     CLINICAL INFORMATION
                                                                                               5

                 b) Except as otherwise provided by the chapter, the result of a test or
Clinical            procedure to determine HIV infection, antibodies to HIV, or infection
Informed            with any probable causative agent of AIDS performed under the
Consent             authorization of a general consent form in accordance with this
(continued)         section may be used only for diagnostic or other purposes directly
                    related to medical treatment.

              Texas Health and Safety Code may be found at the following website:
              http://www.statutes.legis.state.tx.us/?link=HS.

              The PHC Clinical Guidelines gives providers guidance in providing direct
Clinical      patient care services. The guidelines are in a table format at the end of this
Guidelines    chapter.

              Specific requirements for PHC are:
                 • Comprehensive medical and social history and updated as clinically
                      indicated;
                 • Baseline and per iodic physical exam (PE) initially and updat ed as
                      clinically indicated;
                 • Health Risk Assessment (HRA) initially and updat ed as clinically
                      indicated; and
                 • Patient education for health risks identified in the HRA.

              Services operating under specific DSHS guidelines/standards should be
              provided according to that particular program’s requirements in addition to
              PHC requirements. Specific guidelines cover, but are not limited to,
              services such as family planning, child health, immunizations, maternity,
              diabetes management, and case management.

              Protocols, Standing Delegation Orders and Procedures

              Contractors that provide clinical services must develop and maintain written
              clinical protocols and standing delegation orders (SDOs) in compliance
              with statutes and r ules governing medical and nursing practice and
              consistent with national evidence-based clinical guidelines. The written
              clinical protocols and/or SDOs must be signed by the Medical Director or
              supervising physician on an annual basis or more often if changes are
              required. When DSHS revises a policy, contractors need to incorporate the
              revised policy into their written procedures.

              Protocols
              Contractors that employ Advanced Practice Nurses or Physician Assistants
              must have written protocols to delegate authorization to initiate medical
              aspects of client care. The protocols must be agreed upon and signed by
              the supervising physician and the physician assistant and/or advanced
              practice nurse, reviewed and signed at least annually, and maintained on
              site. The protocols need not describe the exact steps that an advanced
              practice nurse or a phy sician assistant must take with respect to each
              specific condition, disease, or symptom.


                                                                                September 2011
                                                                             SECTION FOUR
                                                                     CLINICAL INFORMATION
                                                                                              6


Clinical      Standing Delegation Orders
Guidelines    Contractors that employ unlicensed and licensed personnel, other than
(continued)   advanced practice nurses or physician assistants, whose duties include
              actions or procedures for a patient population with specific diseases,
              disorders, health problems or sets of symptoms, must have written SDOs
              in place. S DOs are instructions, orders, rules, regulations or procedures
              that specify under what set of conditions and circumstances actions should
              be instituted. The SDOs delineate under what set of conditions and
              circumstances an RN, LVN, or non-delineate under what set of conditions
              and circumstance an RN, LVN, or non-licensed health care provider
              (NLHP) actions or tasks may be initiated in the clinical setting, and provide
              authority for use with patients when a physician or advance practice
              provider is not on the premises, and or prior to being examined or
              evaluated by a physician or advance practice provider. Example: SDO for
              assessment of Blood Pressure/Blood Sugar which includes an RN, LVN or
              NLHP that will perform the task, the steps to complete the task, the
              normal/abnormal range, and the process of reporting abnormal values.
              Other applicable SDOs when a physician is not present on-site may
              include, but are not limited to:
                      • Obtaining a personal and medical history;
                      • Performing an app ropriate physical exam and t he recording of
                          physical findings;
                      • Initiating/performing laboratory procedures;
                      • Administering or providing drugs ordered by voice
                          communication with the authorizing physician;
                      • Providing pre-signed prescriptions for:
                             o Oral contraceptives;
                             o Diaphragms;
                             o Contraceptive creams and jellies;
                             o Topical anti-infective for vaginal use;
                             o Oral anti-parasitic drugs; or
                             o Antibiotic drugs for treatment of venereal disease
                      • Handling medical emergencies – to include on-site management
                          as well as possible transfer of client;
                      • Giving immunizations; or
                      • Performing pregnancy testing.

              SDOs are distinct from specific orders written for a particular patient. The
              SDOs must be dated and signed by the physician who is responsible for
              the delivery of medical care covered by the orders. The SDOs must be
              reviewed and signed at least annually.


              Patient Education
              In addition to the above, contractors must have written plans for patient
              education that include goals and c ontent outlines to ensure consistency
              and accuracy of information provided. Plans for patient education must be
              reviewed and signed by the Medical Director.


                                                                               September 2011
                                                                             SECTION FOUR
                                                                     CLINICAL INFORMATION
                                                                                               7


Clinical      Resources
Guidelines    Requirements addressing scope of practice and delegation of medical and
(continued)   nursing acts can be accessed at the following websites:

              http://www.tmb.state.tx.us/ (Texas Medical Board); and
              http://www.ben.state.tx.us/ (Board of Nurse Examiners for the State of
              Texas.

              Rules that are most pertinent to this topic are:
              Texas Administrative Code, Title 22, Part 9, Chapter 193;
              Texas Administrative Code, Title 22, Part 11, Chapters 221 and 224; and
              Texas Administrative Code, Title 22, Part 9, Chapter 185 ( Physician
              Assistant Scope of Practice).

              Emergency Responsiveness

              Contractors must be ad equately prepared to handle clinical emergency
              situations, as follows:
                  • There must be a written plan for the management of on-site medical
                      emergencies, emergencies requiring ambulance services and
                      hospital admission, and em ergencies requiring evacuation of the
                      premises.
                  • Each site where sterilization procedures are performed must have
                      an arrangement with a licensed facility for emergency treatment of
                      any surgical complication. If sterilization procedures are performed
                      in a freestanding surgical care center or on an inpatient basis in a
                      hospital, Medicare standards applicable to the facility and staff must
                      be met.
                  • Each site must have staff trained in basic cardiopulmonary
                      resuscitation (CPR) and emergency medical action. Staff trained in
                      CPR must be present during all hours of clinic operation.
                  • There must be written protocols to address vaso-vagal reactions,
                      anaphylaxis, syncope, cardiac arrest, shock, hemorrhage, and
                      respiratory difficulties.
                  • Each site must maintain emergency resuscitative drugs, supplies,
                      and equipment appropriate to the services provided at that site and
                      appropriately trained staff when patients are present.
                  • Documentation must be maintained in personnel files that staff has
                      been trained regarding these written plans or protocols.




                                                                                September 2011
                                                                          SECTION FOUR
                                                                  CLINICAL INFORMATION
                                                                                           8

              Patient Health Record (Medical Record)
Clinical
Guidelines    Contractors must ensure that a patient health record (medical record) is
(continued)   established for every client who obtains services. These records must be
              maintained according to accepted medical standards and State laws,
              including those governing record retention.

              All client records must be:
                   • Complete, legible, and ac curate documenting all clinical
                       encounters, including those by telephone;
                   • Written in ink without erasures or deletions; or documented by
                       Electronic Medical Record (EMR);
                   • Signed by the provider making the entry, including name of
                       provider, provider title and date for each entry;
                            o Electronic signatures are allowable to document provider
                               review of care. H owever, stamped signatures are not
                               allowable.
                   • Readily accessible to assure continuity of care and availability to
                       client;
                   • Systematically organized to allow easy documentation and prompt
                       retrieval of information;
                   • Maintained to safeguard against loss or unauthorized access and to
                       assure confidentiality (complying with HIPAA regulations); and
                   • Secured by lock when not in use.

              The patient health record must include:
                 • Client identification and personal data;
                 • Completed Screening and Eligibility Determination Form for Medical
                     Services Assistance;
                 • Completed Statement of Applicant’s Rights and Responsibilities
                     signed by the client or responsible party;
                 • Copies of acceptable documentation establishing income,
                     residency, and family composition;
                 • Copy of Medicaid and/or CHIP denial letter, if applicable;
                 • Preferred language/method of communication;
                 • Patient contact in formation with the best way to reach patient in
                     such a m anner that facilitates continuity of care, assures
                     confidentiality, and adheres to HIPAA* regulations;
                 • Medical history, (in Medical History and Risk Assessment);
                 • Physical examination (in Physical Assessment);
                 • Laboratory and other diagnostic tests orders, results and follow-up;
                 • Assessment or clinical impression;
                 • Plan of care, including education/counseling, treatment, special
                     instructions scheduled antenatal visits and referrals;
                 • Documentation on follow-up of missed appointments;
                 • Informed consent documentation;
                 • Refusal of services documentation;
                 • Medication and ot her allergic reactions recorded prominently in
                     specific location; and


                                                                             September 2011
                                                                             SECTION FOUR
                                                                     CLINICAL INFORMATION
                                                                                              9


Clinical         •   Problem list.
Guidelines
(continued)   Preventive Services

              PHC providers may, but are not required to, use the current edition of the
              Guide to Clinical Preventive Services, developed by the U.S. Preventive
              Services Task Force, as guidelines for providing clinical preventive
              services such as health screening and client education. The guide can be
              accessed at: http://www.ahrg.gov/clinic/prevenix.htm.

              Vaccines

              PHC contractors are encouraged to become a Texas Vaccines for Children
              (TVFC) provider. The TVFC program supplies free vaccines to providers to
              vaccinate eligible patients from birth through age 18 y ears. A ll vaccines
              routinely recommended by the Advisory Committee on Immunization
              Practices (ACIP) and a pproved by the Centers for Disease Control and
              Prevention (CDC) are offered by the TVFC program.

              Additional information on pr ovider enrollment can be found at:
              http://www.dshs.state.tx.us/immunize/tvfc/default.shtm or by calling 1-800-
              252-9152.

              To be eligible to enroll in the TVFC, providers must be one of the following:
                 • Physician (Medical Doctor (MD) or Doctor of Osteopathy (DO));
                 • Nurse Practitioner (NP);
                 • Certified Nurse Midwife (CNM); or
                 • Physician Assistant (PA).

              All other health care providers must enroll under the standing delegation
              orders of a physician including:
                  • Pharmacists (RPH);
                  • Nurses (Registered Nurses (RN) or Licensed Vocational Nurses
                      (LVN);
                  • Medical Assistants (MA);
                  • Nurse Assistants (NA); or
                  • Emergency Medical Technicians (EMT).

              Medicaid and CHIP providers must enroll in the TVFC or use their privately
              purchased vaccines. They may not refer children to Local Health
              Departments (LHD) or other entities for routinely recommended
              vaccinations. A TVFC Provider Enrollment Form is included in the
              Medicaid provider enrollment packet.

              NOTE: Medicaid and CHIP programs do not reimburse providers for
              the cost of routinely recommended childhood vaccines but do
              reimburse an administration fee.



                                                                                September 2011
                                                                             SECTION FOUR
                                                                     CLINICAL INFORMATION
                                                                                              10

              Pharmaceuticals
Clinical
Guidelines    Pharmaceuticals for the treatment of patients with gonorrhea, chlamydia,
(continued)   and syphilis may be obtained from the DSHS STD/HIV through
              participating Local Health Departments and DSHS regional offices.
              Contractors may use PHC funds for pharmaceuticals provided to patients
              receiving PHC services with the approval of PHC through the Request for
              Proposal (RFP) and c ontract processes. Contractors are encouraged to
              access Prescription Drug Patient Assistance Programs in order to obtain
              prescription medications at no cost or low cost to clients. Many programs
              are listed in the Pharmaceutical Research and Manufacturers of America
              (PhRMA) directory published online at: http://www.phrma.org and
              http://www.rxxassist.org.

              Medicare Prescription Drug Plan

              On January 1, 2006, the Medicare Prescription Drug Plan, Medicare Part
              D, was introduced to provide elderly and di sabled Medicare beneficiaries
              access to prescription drug coverage. Texas beneficiaries pay monthly
              premiums, deductibles, and c o-payments as part of program participation
              and can choose from a number of plans with distinct formularies. Medicare
              provides various premium and c ost-sharing subsidies (“extra help”) to
              assist beneficiaries below 150% FPL with limited assets. The application
              process for extra help, coordinated by the Social Security Administration, is
              a separate process from enrolling in the drug plan. If beneficiaries do not
              enroll when they are first eligible, they may have to pay a higher premium
              amount if they join at a late date. If they have prescription drug coverage
              from other insurance that is the same or better than the Medicare plans,
              they can keep their current coverage and will not have to pay a higher
              premium if they decide to join Part D later.

              Enabling legislation mandates that PHC can only provide services that a
              client is not eligible for through another resource; therefore, Medicare-
              eligible PHC clients must access their prescriptions through a M edicare
              Prescription Drug Plan. PHC contractors that provide supplemental
              prescription drug benefits may provide these benefits to client during the
              application process for Medicare Part D for a period up to 9-days, unless
              extenuating circumstances occur and clients would be harmed if access to
              medication ceased. Contractors must document such circumstances in the
              patient health record.




                                                                               September 2011
                                                                              SECTION FOUR
                                                                      CLINICAL INFORMATION
                                                                                              11


Clinical      Screening for Part D – PHC rules mandate that all PHC contractors,
Guidelines    regardless of whether or not they provide supplemental prescription drug
(continued)   benefits, must screen clients for Medicare Part D eligibility. Applicants and
              clients are eligible for Medicare Part D if they are eligible for Medicare.
              These individuals must be referred to the local health and human services
              agency, local Area Agencies on Aging, Medicare and/or the Social Security
              Administration to enroll in the Medicare Prescription Drug Plan and
              possible extra help in paying for out-of-pocket expenses associated with
              the plans. Resources are provided below.

              Out-of-Pocket Expenses – The Medicare Prescription Drug Plan requires
              beneficiaries to pay out-of-pocket expenses such as premiums,
              deductibles, and co-payment. Beneficiaries that qualify for cost-sharing
              subsidies will receive assistance from Medicare in paying for these
              expenses. I n addition, a catastrophic benefit is available when a c ertain
              threshold of out-of-pocket expenses is reached.           In some cases,
              beneficiaries may pay more for their prescription under Medicare Part D
              PHC rules allow contractors to reimburse clients for cost of cost sharing
              incurred through participation in the Medicare Prescription Drug Plan upon
              the availability of funds. Contractors are responsible for establishing
              agreements with pharmacies participating in the Medicare plans and/or
              implementing a system in which clients are reimbursed their co-payments.

              Resources – General information from Medicare for beneficiaries and
              service providers on Part D:

              Call 2-1-1 for local assistance in applying for Part D and the extra help.

              1-800-MEDICARE / http://www.medicare.gov

              Information on Outreach and Partnerships from Medicare:
              http://www.cms.hhs.gov/partnerships/


              Information on extra help from SSA:
              1-800-772-1213
              http://www.ssa.gov/prescriptionhelp/

              Area Agencies on Aging:
              1-800-252-9240
              http://www.medicarerxoutreach.org

              General information and fact sheets on Medicare Part D:
              www.kff.org/rxdrugs/medicare.cfm




                                                                                 September 2011
                                   SECTION FOUR
                           CLINICAL INFORMATION
                                             12

Reserved for future use.




                                  September 2011
                                                                                                                                       SECTION FOUR
                                                                                                                               CLINICAL INFORMATION
                                                                                                                                                         13

                                                           CLINICAL GUIDELINES
 STANDARD STATEMENT                                   POLICIES & PROCEDURES                                       EVALUATION CRITERIA

     HEALTH ASSESSMENT                    Policy: At sites providing medical care, the provider         Evidence of health history in the record
                                          ensures a complete health history is obtained.
A.   At sites providing medical care,
     a complete initial health history,   Procedures: The health history includes a medical and
     signed and dated by the              social history.                                               DSHS may distribute or provide appropriated
     provider, is obtained and            1. The medical history includes the following:                funds only to patients who show good faith efforts
     updated periodically, or at least       a. Current history                                         to comply with all child abuse reporting guidelines
     annually, for all patients.             b. Hospitalizations                                        and requirements set forth in Chapter 261 of the
                                             c. Allergies, sensitivities or reactions to medicines or   Texas Family Code.
                                             other substances
                                             d. Family history                                          DSHS may distribute funds for medical, dental,
                                             e. Obstetric history and gynecologic history as            psychological, or surgical treatment provided to a
                                             indicated                                                  minor only if consent to treatment is obtained
                                             f. Sexual behavior history, including family planning      pursuant to Chapter 32 of the Texas Family
                                             practices                                                  Code.
                                             g. Mental health history, to include depression and
                                             suicidal thoughts or gestures
                                             h. Nutritional history
                                             i. Developmental (pediatric)
                                             j. Immunization history
                                             k. Occupational hazards or environmental toxin
                                             exposure                                                   Documentation of social history

                                          2. The social history includes the following:
                                             a. Home environment, to include living arrangements
                                             b. Tobacco/alcohol/drugs use/abuse and exposure
                                             c. Family dynamics/problems; e.g., abuse




                                                                                                                                          September 2011
                                                                                                                         SECTION FOUR
                                                                                                                 CLINICAL INFORMATION
                                                                                                                                        14


                                                      CLINICAL GUIDELINES
STANDARD STATEMENT                               POLICIES & PROCEDURES                               EVALUATION CRITERIA

B. At sites providing medical care,   Policy: Medical care providers assess health risk on   Health record
   a health risk assessment is        all clients served.                                    Evidence of health assessment
   completed for all patients.
                                      Procedures: Patients must have a health risk
                                      assessment according to the following:
                                      1. Children ages birth through 20 years of age have
                                         health risk assessments done according to
                                         periodicity of visits, e.g., periodicity chart
                                      2. People aged 21 years and older must have an
                                         initial health risk assessment, which is updated
                                         annually or with change in client status. Health
                                         Risk Assessment includes but is not limited to:
                                         a. Diabetes
                                         b. Heart disease
                                         c. High-risk sexual behavior
                                         d. Violence
                                         e. Injury
                                         f. Malignancy


C. At sites providing medical care,   Policy: The providers of medical care shall provide
   all patients shall receive         preventive education based on health risk or patient
   preventive health education.       need.
                                                                                             Documentation of education provided based on
                                      Procedures: All patients must receive anticipatory     health risk assessment or patient need.
                                      guidance at each visit that covers the following
                                      appropriate areas:
                                      1. Violence
                                         a. Family/domestic




                                                                                                                             September 2011
                                                                                                               SECTION FOUR
                                                                                                       CLINICAL INFORMATION
                                                                                                                              15

                                       CLINICAL GUIDELINES
STANDARD STATEMENT                POLICIES & PROCEDURES                                   EVALUATION CRITERIA
                           b. Gang
                           c. Other types of violence
                     2.   Injury prevention
                           a. Fire arms
                           b. Car safety restraints
                           c. Helmets
                           d. Prevention of other types of injuries
                     3.   Behavior                                               For infants: Pediatric Nutrition Handbook, 5th
                           a. Substance abuse, e.g., tobacco, alcohol,           Edition from the American Academy of
                               chemicals and drugs                               Pediatrics, 2003; Keep Kids Healthy at:
                           b. Safe sex practices                                 http://www.keepkidshealthy.com/infant/infantnu
                     4.   Nutrition                                              trition.html
                           a. Healthy diets
                           b. Weight management                                  For children:
                           c. Folic acid                                         www.kidshealth.org/kid/stay_healthy/food/pyra
                           d. Calcium                                            mid.html
                           e. Other vitamins and minerals
                     5.   Health promotion                                       For adults:
                           a. Immunizations                                      www.lifeclinic.com/focus/nutrition/food-
                           b. Dental care                                        pyramid.asp and
                           c. Physical activity                                  www.nal.usda.gov/fnic/Fpyr/pmap.htm
                           d. Family planning
                           e. Prenatal care
                           f. Newborn care
                     6.   Other education based on specific problems or
                          health risk
                     7.   Anticipatory guidance for teens in addition to above
                          also includes:
                           a. School performance
                           b. Depression
                           c. Suicide




                                                                                                                  September 2011
                                                                                                                                  SECTION FOUR
                                                                                                                          CLINICAL INFORMATION
                                                                                                                                                      16

                                                       CLINICAL GUIDELINES
STANDARD STATEMENT                                POLICIES & PROCEDURES                                     EVALUATION CRITERIA

D. All patients or their guardians    Policy: Providers shall ensure that all patients
   shall provide consent for          consent for services.
   services/treatment.

                                      Procedures:                                                 Health record
                                      1. Notification and consent of the parent/legal             A signed and dated consent
                                          guardian for all services provided to a minor           Texas Family Code, Chapter 32
                                          patient is required except for those patients for
                                          whom the minor may consent independently
                                          according to those stated in Family Code §32.003.
                                      2. All patients and/or guardians must provide signed
                                          consent for immunizations.



E. At sites providing medical         Policy: At sites providing medical services, a baseline     Reference for interventions: Guide to Clinical
   care, a baseline physical exam     PE is conducted in conjunctions with the initial history,   Preventive Services. This reference also
   (PE) is conducted on all           laboratory tests, and interventions. In addition, on        contains interventions for high-risk individuals.
   patients. Periodic physical        subsequent visits a targeted PE, screening procedures,
   exams are conducted based          and interventions are conducted.
   upon presenting symptoms,
   health risk factors, a review of   Procedures:
   systems, or according to the       1. As an integral part of the complete health assessment,   THSteps Periodicity Schedule can be found at:
                                      the PE is based upon the patient’s presenting symptoms,     http://www.dshs.state.tx.us/thsteps.
   THSteps Periodicity Schedules
                                      review of systems (ROS), past history, and health risk
   for children.
                                      factors.

                                      2. Laboratory and interventions (general non-high risk
                                      population)

                                          a. Blood pressure




                                                                                                                                     September 2011
                                                                                                             SECTION FOUR
                                                                                                     CLINICAL INFORMATION
                                                                                                                           17

                                  CLINICAL GUIDELINES
STANDARD STATEMENT          POLICIES & PROCEDURES                                       EVALUATION CRITERIA

                     Health Risk Conditions Addressed: Coronary               Centers for Disease Control and Prevention
                     heart disease, congestive heart failure, cerebral        http://www.cdc.gov/bloodpressure/about.htm
                     vascular accident (stroke), ruptured aortic aneurysm,
                     renal disease, and retinopathy.

                     Recommended Practice:
                        1. At least once every two years for 140/85
                        2. Annually if diastolic blood pressure of 85-89
                        3. Higher blood pressure require more frequent
                           measurements
                        4. Children and adolescents – annually for ages       http://wonder.cdc.gov/wonder/prevguid/p0000109
                           3-20                                               /p0000109.asp#head008001000000000

                     b. Height, weight and BMI or appropriate
                     assessment for overweight/obesity.

                     Health Risk Conditions Addressed: Overweight
                     and obesity, which are associated with adult-onset
                     diabetes, hypertension, et al.

                     Recommended Practice: Initial visit, then
                     periodically.

                     c. Total blood cholesterol                               U.S. Preventive Services Task Force
                                                                              http://www.ahrq.gov/clinic/uspstfix.htm
                     Recommended Practice: If no risk factors for
                     coronary heart disease, routinely test men starting at
                     35 years old and women starting at age 45. If risk
                     factors for coronary heart disease are present,
                     routinely screen men and women starting at age 20.

                     d. Cervical Cancer Screening for women




                                                                                                                September 2011
                                                                                                              SECTION FOUR
                                                                                                      CLINICAL INFORMATION
                                                                                                                                 18

                                     CLINICAL GUIDELINES
STANDARD STATEMENT              POLICIES & PROCEDURES                                     EVALUATION CRITERIA


                         Health Risk Conditions Addressed: Cervical
                         Cancer


                         Recommended Practice:
                         • Cervical cancer screening test (i.e., Pap test)      http://www.acog.org/departments/dept_notice.cfm
                                                                                ?recno=20&bulletin=5021
                         In 2009, ACOG updated their cervical cancer
                         screening guidelines to include:                       http://www.acog.org/from_home/publications/press_
                                                                                releases/nr11-20-09.cfm
                         •   Cervical cancer screening should begin at age 21
                             years.                                             Other organizational resources:
                         •   Cervical cytology screening is recommended
                             every 2 years for women between the ages of 21     http://www.cancer.org/docroot/NWS/content/NWS
                             years and 29 years.                                _1_1x_ACOG_Revises_Cervical_Cancer
                         •   Women aged 30 years and older who have three       _Screening_Guidelines.asp
                             consecutive negative cervical cytology screening
                             test results and who have no history of CIN 2 or   http://www.ahrg.gov/clinic/uspstf/uspscerv.htm
                             3, are not HIV infected, are not
                             immunocompromised, and were not exposed to
                             DES in utero, may extend the interval between      American Cancer Society
                             cervical cytology examinations to every 3 years.   http://gantdaily.com/2010/08/03/whtf-new-
                         •   Both liquid-based and conventional methods of      cervical-cancer-screening-guidelines-the-pap-
                             cervical cytology are acceptable of screening.     test/

                     Note: Regardless of the frequency of cervical cancer
                     screening, annual gynecologic examinations are still
                     recommended, including pelvic exams, when indicated.




                                                                                                                  September 2011
                                                                                                             SECTION FOUR
                                                                                                     CLINICAL INFORMATION
                                                                                                                               19

                                  CLINICAL GUIDELINES
STANDARD STATEMENT          POLICIES & PROCEDURES                                       EVALUATION CRITERIA
                     e. Colorectal Screening                                  American Cancer Society
                                                                              http://www.nccrt.org/Standards/STDDetail.aspx?a
                     Health Risk Conditions Addressed: Colorectal             rticle_id=374
                     Cancer.

                     Recommended Practice:
                     1. Average risk – screen men and women 50 years
                        of age and older.
                     2. High risk – screen prior to 50 years and/or more
                        often if have any colorectal cancer risk factors.
                     3. Patient to visit with physician about which test is   Center for Disease Control and Prevention
                        best.                                                 http://www.cdc.gov/cancer/breast/fact_mammogr
                     4. Screening options are fecal occult blood testing      ams.htm
                        (FOBT), flexible sigmoidoscopy, combination of
                        FOBT and flexible sigmoid, colonoscopy, or            America Cancer Society
                        double-contrast barium enema, or CT                   http://ww2.cancer.org/docroot/NWS/content/NWS
                        colonography.                                         _1_1x_Updated_Breast_Cancer_Screening_Guid
                                                                              elines_Released.asp
                     f. Mammography

                     Health Risk Conditions Addressed: Breast cancer          http://www.dshs.state.tx.us/immunize/schedule/d
                                                                              efault.shtm
                     Recommended Practice: Every 1-2 years, with
                     mammography and annual CBE, for women aged
                     50-69.

                     g. Immunizations

                     Health Risk Conditions Addressed: Tetanus (lock          http://www.dshs.state.tx.us/immunize/adult_sched.s
                     jaw), Rubella (measles), Influenza (including            htm
                     influenza pneumonia), and Pnuemococcal
                     pneumonia.




                                                                                                                September 2011
                                                                                                                                  SECTION FOUR
                                                                                                                          CLINICAL INFORMATION
                                                                                                                                                       20

                                                        CLINICAL GUIDELINES
STANDARD STATEMENT                                POLICIES & PROCEDURES                                       EVALUATION CRITERIA
                                          Recommended Practice:
                                          1. Tetanus, diphtheria, pertussis (Td/Tdap) booster
                                             - Every 10 years
                                          2. Rubella – Based on a history of rubella
                                             vaccination or documented serology. Non-               http://www.dshs.state.tx.us/immunize/adult_sched
                                             pregnant female patients of childbearing age with
                                             unknown or inadequate rubella immunity must be
                                             provided vaccination on-site or referred
                                             appropriately.
                                          3. Influenza – annually beginning at age 50
                                          4. Pneumococcal – once beginning at age 65,
                                             however a repeat may be indicated after five
                                             years.

                                          h. Vision and hearing screening

                                          Health Risk Conditions Addressed: Visual and
                                          hearing impairment.

                                          Recommended Practice: Periodically beginning at
                                          age 65 (optimal frequency not determined).

F. Episodic or Acute Care Visit       Policy: The physical assessment and laboratory
                                      tests/interventions must be based on the presenting
                                      complaints.

G. All clients shall be referred to   Policy: Providers must refer patients to their provider       Health record Documentation of a referral
other appropriate services as         network as necessary.
needed.
                                      Procedures:
                                      All patients who require a referral will be referred to the
                                      appropriate provider within their provider network.




                                                                                                                                     September 2011
                                                                      SECTION FOUR
                                                              CLINICAL INFORMATION
                                                                                      21


Clinical         1. For services determined to be necessary, but which are not
Guidelines          provided by the contractor, patients must be referred to other
(continued)         resources for care. Contractors are expected to have established
                    communications with Federally Qualified Health Centers (FQHCs)
                    or DSHS funded organizations that provide primary care services or
                    breast cancer and cervical cancer screening and diagnostic
                    services for referral purposes if there are any such providers within
                    their service area. Whenever possible, patients should be given a
                    choice of referral resources from which to select. When a patient is
                    referred to another resource because of an abnormal finding or for
                    emergency clinical care, the contractor must:
                        • Make arrangements for the provision of pertinent patient
                            information to the referral resource (obtaining required
                            patient consent with appropriate safeguards to ensure
                            confidentiality – i.e., adhering to HIPPA* regulations);
                        • Advise patient about his/her responsibility in complying with
                            the referral;
                        • Counsel patient on the importance of the referral and follow-
                            up method; and
                        • Follow up to determine if the referral because of an
                            abnormal finding was completed and document the outcome
                            of the referral.
                        *Health Insurance Portability and Accountability Act of 1996

              Patients who have abnormal clinical breast exam (CBE) or cervical
              cytology findings may be scheduled to return for repeat exams if this is
              considered to be appropriate follow up by the clinician. For patients whose
              cervical cytology test or CBE results in an abn ormal finding that requires
              referral for services beyond those available through primary health care,
              contractors are encouraged, whenever possible, to refer to a DSHS Breast
              and Cervical Cancer Services contractor. In order to promote the most
              effective use of limited resources, primary health care contractors’
              clinicians should be familiar with nationally recognized guidelines and
              algorithms describing recommended practice regarding abnormal cervical
              cytology and CBE results (See Appendices).




                                                                        September 2011
     SECTION FIVE


 REIMBURSEMENT, DATA
COLLECTION & REPORTING
                                                                                SECTION FIVE
                                                 REIMBURSEMENT, DATA COLLECTION & REPORTING
                                                                                                         1


Reimbursement   The Health and S afety Code and T exas Administrative Code require PHC
                activities to be ev aluated on an annual basis. The evaluation process
                includes monthly, quarterly, and annual program and fiscal reporting as well
                as desk and/or site reviews by DSHS staff. Instructions for reimbursement
                and/or data collections are included in this section of the manual. Forms for
                reimbursement and data collection are located in the Forms section.

                Billing

                Primary Health Care services contract amounts are ceilings against which
                contractors may bill for providing primary health care services to PHC eligible
                clients. Once this dollar ceiling has been reached, no further funds will be
                available for reimbursement. Contractors may only bill for services provided
                to clients who have been screened for potential Medicaid, CHIP, Title V, Title
                X, and Title XX eligibility and been deem ed as full-service, supplemental, or
                presumptive eligible.

                Categorical reimbursement for cost of providing services shall be b illed on
                the State of Texas Purchase Voucher (Form B-13) and submitted
                simultaneously to the Contract Development & Support Branch (CDSB)
                (cdsb@dshs.state.tx.us) and the Accounting Section/Claims Processing Unit
                (CPU) (invoices@dshs.state.tx.us). See Form B-13 in the Forms Section for
                the PHC State of Texas Purchase Voucher and an example of a completed
                PHC Purchase Voucher.

                Reimbursement request for direct care services will be s ubmitted on a
                monthly basis. E ach request will cover services provided, or expenses
                incurred, in the preceding month as applicable to the contract attachment.
                Requests should be s ubmitted within 30 da ys of the end of the preceding
                month and w ithin 60 day s of providing the service. A ppropriate financial
                records must be maintained for review by DSHS through the quality
                assurance review process and/or fiscal monitoring and/or programmatic desk
                reviews.

                To be paid promptly, Purchase Vouchers must identify the Vendor
                Identification Number, DSHS document number and Attachment number,
                and the 10-digit Purchase Order Number. Incorrect identification numbers
                may delay payment. Failure to complete these sanctions will delay payment.
                The Purchase Voucher must also include the total number of unduplicated
                clients determined eligible and provided a primary care service for the month
                (bottom of box #20 on the voucher). The number of clients entered on the
                voucher must match the number of unduplicated clients served that is
                reported on the corresponding monthly PHC– 200 Report. If a supplemental
                or amended voucher is submitted, an amended PHC–200 Report must also
                be submitted to the PHC mailbox to reflect the changes in client numbers
                and/or dollar amounts. The PHC program


                must approve the monthly PHC-200 Report before the corresponding
                                                                                             September 2011
                                                                                SECTION FIVE
                                                 REIMBURSEMENT, DATA COLLECTION & REPORTING
                                                                                                           2

Reimburseme   monthly voucher may be processed for payment. Requests submitted
nt            without the required program reports will not be appr oved for payment.
(continued)   Vouchers and/or reports submitted with incorrect or missing information will
              be rejected and the contractor will be contacted to remedy the problem.

              Contractors must continue to submit a S tate Purchase Voucher and
              supporting monthly program reports even after they have reached contract
              ceilings. Any cost over the contract ceiling after deducting program income
              should be reflected under “Non-DSHS Funding” on the voucher and on the
              FSR. This submission is required to continue reporting expenditures on any
              program income collected monthly, and t o provide DSHS with statistical
              information about the use of services.

              Non-Reimbursable Expenditures

              PHC will not reimburse services for individuals eligible for another program or
              clients who do not complete the respective eligibility process. Failure to fully
              comply with all requirements to apply for Medicaid or CHIP services does not
              deem a client eligible for PHC services.

              Services are often provided to clients whose screening results indicate they
              are potentially Medicaid or CHIP eligible, but the client has not yet completed
              or received notification of acceptance or rejection of an application. PHC
              may cover services delivered on the initial date of contact after the eligibility
              determination is complete and Medicaid and/or CHIP deny eligibility. Such a
              denial of eligibility must be documented in the client’s file for the contractor to
              bill for the initial day’s services to PHC. Once the program’s denial letter is
              received, with the exception of presumptive eligibility, the services provided
              on the initial day of service may be billed to PHC for reimbursement.

              Services delivered to PHC clients with supplemental service benefits may
              only be billed if a supplemental service was provided at the time of the visit.

              Submission of Vouchers

              Monthly reimbursement requests should be s ubmitted within 30 d ays
              following the end o f the month covered by the bill. A ll claims for
              reimbursement for services delivered must be s ubmitted within 60 da ys of
              the end o f the contract term. I f contractors have services that occurred
              during the contract period left to bill after the August Purchase Voucher has
              been submitted, contractors can bill those services using a Purchase
              Voucher and a P HC-200 report marked FINAL and submit the forms on or
              before October 31. PHC contracts require closure of the contract attachment
              within 60 days of the end of the contract term.               All requests for
              reimbursement must be submitted by email (preferred), or fax to CDSB.


              The Purchase Voucher must be submitted by fax or email to CPU. Requests
              postmarked more than 60 days following the end of the Contract Attachment
              will not be paid. An original mailed Financial Status
                                                                                               September 2011
                                                                                SECTION FIVE
                                                 REIMBURSEMENT, DATA COLLECTION & REPORTING
                                                                                                       3

Reimbursement   Report (Form 269a) final report must be filed with the DSHS Accounting
(continued)     Section, Claims Processing Unit and by email (preferred) or fax to CDSB
                no later than 60 days after the contract term. The 269a must be marked as
                FINAL and include all reimbursements and adjustments in payments for the
                contract term.

                Altering of Forms – Contractors are required to use the Excel format for
                ease of processing. None of the billing or the reporting forms may be altered
                in any manner. State Purchase vouchers should not be al tered to itemize
                expenses for PHC services provided. Vouchers should be submitted for the
                total monthly reimbursement amount only. P lease use at least 10 p t sized
                font when entering data. Illegible information will be q uestioned and/or
                returned.




                                                                                           September 2011
                                                                                        SECTION FIVE
                                                         REIMBURSEMENT, DATA COLLECTION & REPORTING
                                                                                                                          4


Data
Collection &   PROGRAM INFORMATION
               Program Name: Primary Health Care
Reporting
               Contract Type: Categorical
               Contract Term: September 1—August 31

               VOUCHER: Voucher 1
               Voucher Name: State of Texas Purchase Voucher Form B-13
               Submission Date: Within 30 days following the end of the month. Final due within 60 days
               after end of contract term.
               Submit Copy to:
                 Name of Unit/Branch        Original       Accepted Method of                    #
                                           Required            Submission                    Copies
                                           Yes    No
                Contract Development &            X       Email (preferred), or Fax              1
                Support Branch (CDSB)
                Claims Processing Unit            X            Email or Fax                     1
                         (CPU)

               Instructions: Submit one Form B-13 voucher to CDSB and one Form B-13 voucher to CPU.
               Must submit to both.


               REPORT: Report 1
               Report Name: PHC 200 Monthly Report Form
               Submission Date: Within 5 working days following the end of each month.
               Submit Copy to:
                Name of Unit/Branch       Original         Accepted Method of                          #
                                         Required              Submission                            Copies
                                         Yes    No
                 Primary Care Group             X         Email (preferred), or Fax                       1
                       (PCG)

               Instructions: Submit PHC 200 Monthly Report Form to PCG only.
               For CY 11, reports are due 1/7, 2/7, 3/7, 4/7, 5/6, 6/7, 7/8, 8/5, 9/8, 10/7, 11/7, 12/7
               .For CY 12, reports are due 1/6.2/7,3/7,4/6,5/7,6/7,7/9, 8/7, 9/7, 10/5, 11/7, 12/7

               NOTE: If you do not submit your PHC 200 by the due date, voucher payments may be
               held.

               REPORT: Report 2
               Report Name: Financial Status Report 269A
               Submission Date: Quarterly, Sep 1-Nov 30, Dec 1-Feb 28, Mar 1-May 31, and Jun 1-Aug
                                                                           th
               31. Submit 30 days after the end of each quarter. The 4 quarter is the final report and due
                                                                        th
               within 60 days after the end of the contract term. The 4 quarter report includes all final
                                                                                         th
               charges and expenses associated with the program contract. Mark the 4 quarter report as
               “Final”.
                 Name of Unit/Branch          Original          Accepted Method of                    #
                                             Required               Submission                   Copies
                                             Yes No
                         CDSB                        X         Email (preferred), or Fax              1
                          CPU                  X                Email scanned signed                  1
                                                                document, fax or mail
               Instructions: Form 269A must have an original signature f(scanned email or fax)..




                                                                                                              September 2011
                                                                                    SECTION FIVE
                                                     REIMBURSEMENT, DATA COLLECTION & REPORTING
                                                                                                      5


Data               REPORT: Report 3
Collection &       Report Name: PHC 300 Annual Report
                   Submission Date: Within 60 days following the end of the contract period
Reporting
                   Submit Copy to:
(continued)                                Original         Accepted Method of
                   Name of Unit/Branch    Required               Submission                # Copies
                                         Yes     No
                    Primary Care Group
                          (PCG)                  X         Email (preferred), or Fax          1

                   Instructions: Submit PHC 300 Annual Report Form to PCG only.


                          Email               CDSB      cdsb@dshs.state.tx.us
                        Addresses:            CPU       invoices@dshs.state.tx.us
                                              PCG       PrimaryHealthCare@dshs.state.tx.us
                           Fax                CDSB      (512) 776-7521
                         Numbers:             CPU       (512) 776-7442
                                              PCG       (512) 776-7713
                                                        Please use mail codes on all mail coming
                                                        into DSHS to ensure accurate delivery.
                           Mail               CDSB      Mail code 1914
                          Codes:              CPU       Mail code 1940
                                              PCG       Mail code 2831
                                                        Claims Processing Unit, Mail Code 1940
                     Mailing Address                    Department of State Health Services
                         for CPU:                       P.O. Box 149347
                                                        Austin, TX 78714-9347
                   Last Updated Reviewed: 6/8/10



               Quarterly Financial Status Report (FSR or Form 269a) must be submitted
               directly to the DSHS Accounting Section, Claims Processing Unit and the
               CDSB within 30 days of the completion of the quarter. This form requires an
               original signature for CPU. ** New For FY10: Scanned signed FSRs are
               acceptable. A scanned document may be emailed or faxed to CPU.

               The fourth quarter Financial Status Report should be marked as “FINAL”
               and submitted within 60 day s of the completion of the contract year to the
               DSHS Accounting Section, Claims Processing Unit and to CDSB. This form
               requires an original signature for CPU.




Program        PHC-200 Monthly Report – The following instructions are provided to help
Activity       complete the monthly PHC-200. Fo r the purposes of this report, the term
Reports        “unduplicated” is defined as counting a client/individual only once during the
               reporting time specified. (See Form 200 reporting form)




Program        The purpose of the PHC-Form 200 Monthly report is to provide the following
                                                                                        September 2011
                                                                              SECTION FIVE
                                               REIMBURSEMENT, DATA COLLECTION & REPORTING
                                                                                                       6

Activity      information to DSHS:
Reports           • PHC caseload, and
(continued)       • Contractor’s expenditure levels by PHC service

              PHC-200 Monthly report must be completed and submitted to DSHS Primary
              Care Group (PCG) within 5 w orking days of the month following the report
              month.

              Email Form 200 to PCG – PrimaryHealthCare@dshs.state.tx.us (preferred), or
              fax to DSHS PCG at 512/776-7713.

              General Information:
              Contractor: Name of contractor on DSHS contract
              Report or Amended Report: E nter month and year the expenditures are
              spent/paid.

              Any amendments to a report should be marked as “Amended” and submitted
              on the Form 200. The amended item(s) should be circled, highlighted,
              bolded or identified in some way.


Sanctions     Sanctions Due to Non-Compliance With Reporting

              The Performance Management Unit will apply the following procedures when
              reports and/or vouchers are not received by the required deadlines:

              Fifteen (15) calendar days after any report or voucher is due – DSHS notifies
              the contractor to request that the monthly report or voucher be submitted
              within five (5) business days. N ote: P ayments cannot be pr ocessed until
              correct and complete information is received.

              Five (5) business days after the written notice is sent – The manager of the
              Contract Management Branch (CMB) will determine if technical assistance
              (TA) should be provided. I f the contract has frequently been late in
              submitting reports and billing, contract sanctions may be imposed.

              Contract sanctions – According to Article XIV of the DSHS Contract General
              Provisions (Core/Sub-recipient), the list of sanctions that may be imposed is
              not limited to the following:

                 •   Require contactor to receive technical or managerial assistance;
                 •   Temporary withhold cash payments;
                 •   Permanently withhold cash payments;
                 •   Disallow use of all or part of the funds allocated to the contract;
                 •   Delay execution of a new contract or renewal;
                 •   Reduce funding for the contract;
                 •   Suspend all or part of the contract;
                 •   Terminate the contract; or
                 •   Deny additional or future contracts or renewals.
Sanctions
                                                                                           September 2011
                                                          SECTION FIVE
                           REIMBURSEMENT, DATA COLLECTION & REPORTING
                                                                     7



Reserved for future use.




                                                         September 2011
FORMS
                           DSHS FUNDING SOURCE – Application for Health Care Assistance
                           FUENTE DE FONDOS DEL DSHS – Solicitud de asistencia médica
                                            Applicant Information / Información del solicitante
 Name (Last, First, Middle) / Nombre (apellido y primer y          Home Telephone Number / Teléfono de la casa             Email Address / Correo
                    segundo nombre)                                                                                        electrónico




Texas Residence Address (Street or P.O. Box) / Dirección                   City / Ciudad            County / Condado       State / Estado       ZIP / Código
residencial en Texas (calle o apartado postal)                                                                                                  postal



                                        Household Information / Información de la unidad familiar
Fill in the first line with information about yourself. Fill in the remaining lines for everyone who lives in the house with you for which you are
legally responsible. / Llene la primera línea con información acerca de usted mismo. Llene las líneas restantes por todas las personas que viven con
usted, y por las que es legalmente responsable.
                                                                                                                                          U.S. Citizen
       Name (Last, First, Middle)           SSN (optional)        Date of Birth     Age      Sex       Race       What Relation to         Ciudadano
   Nombre (apellido y primer y segundo   Núm. del Seguro Social      Fecha de      Edad      Sexo      Raza              you?            estadounidense
                nombre)                        (opcional)                                                        Parentesco con usted   Yes / Sí     No
                                                                    nacimiento
1.                                                                                                                Self / Yo mismo
2.

3.

4.

5.

6.

List all of your household’s income below. Be sure to include the following: Government checks; money from work; money you collect from
charging room and board; cash gifts, loans, or contributions from parents, relatives, friends, and others; sponsor’s income; school grants or
loans; child support; and unemployment. / Haga una lista de los ingresos de su unidad familiar a continuación. Asegúrese de incluir: cheques del
gobierno; dinero por trabajo; dinero que recibe por cobros de hospedaje y comida; regalos en efectivo, préstamos, o aportaciones de sus padres,
familiares, amigos y otras personas; ingresos del patrocinador; becas o préstamos escolares; manutención de niños o pagos por desempleo.

     Name of person receiving         Name of agency, person, or                   Amount received                 How often received? (daily, weekly,
             money                    employer who provides the                    Cantidad recibida                 every two weeks, twice a month,
     Nombre de la persona que                   money                                                               monthly?) ¿Con qué frecuencia lo
         recibe el dinero            Nombre de la agencia, persona o                                               recibe? (Diariamente, semanalmente,
                                     empleador que provee el dinero                                                  quincenalmente o mensualmente)




Do you have an immediate medical need? ¿Tiene usted alguna necesidad médica inmediata?                                               Yes / Sí      No
Do you – does any one in your household – have health care coverage (Medicaid, Medicare, CHIP, health                                Yes / Sí      No
insurance, V.A., Tricare, etc.)? ¿Tiene usted o alguien de su unidad familiar cobertura médica (Medicaid, Medicare,
CHIP, seguro medico, V.A., Tricare, etc.)?
If yes, who? / Si contestó que “Sí”, ¿quién?
Do you – does any one in your household – have any special circumstances? ¿Tiene usted o alguien de su unidad                        Yes / Sí      No
familiar alguna circunstancia especial?
If yes, who? Si contesta que “Sí”, ¿quién?

The statement I have made, including my answers to all questions, are true and correct to the best of my knowledge and belief. I agree to give
eligibility staff any information necessary to prove statements about my eligibility. I understand that giving false information could result in
disqualification and repayment. A mi leal saber y entender, la declaración que he hecho y mis respuestas a todas las preguntas son verdaderas y
correctas. Me comprometo a dar al personal de verificación de requisitos toda la información necesaria para comprobar mis declaraciones sobre dichos
requisitos. Yo entiendo que dar información falsa podría causar que me descalifiquen y que tenga que devolver el pago al Programa.
Signature – Applicant / Firma – Solicitante         Date / Fecha        Signature – Spouse (if applicable) / Firma – Cónyuge (de ser aplicable) Date / Fecha

Signature – Person Who Helped Complete this Application –                  Relationship to Client / Relación con el cliente                 Date / Fecha
Firma – Persona que ayudó a completar esta solicitud


                                                                                                                                        EF05-13229
                      DSHS FUNDING SOURCE – Application for Health Care Assistance
                      FUENTE DE FONDOS DEL DSHS – Solicitud de asistencia médica

      APPLICATION FOR HEALTH CARE ASSISTANCE                                      SOLICITUD DE ASISTENCIA MÉDICA

     1.   Complete name and address;                                     1.   Nombre y dirección completos;
     2.   Applicant and spouse (if applicable) must sign and             2.   El solicitante y el/la cónyuge (de ser aplicable) deben
          date the application; and                                           firmar y fechar la solicitud y
     3.   Answer as many questions as possible on this                   3.   Conteste tantas preguntas como pueda en esta solicitud
          application
                                                                     Entregue su solicitud, o mándela por correo, hoy mismo aunque no
Turn in or mail back the application today even if all the           conteste todas las preguntas.
questions are not answered.
                                                                                         RESPONSABILIDADES
                     RESPONSIBILITIES
                                                                     Los solicitantes son responsables de completar la primera página
                                                                     del formulario de evaluación y determinación de requisitos de
Applicants are responsible for completing page one of the
                                                                     servicios de asistencia médica.
screening and eligibility form for medical services assistance.
                                                                     Los solicitantes son responsables de proporcionar los documentos
Applicants are responsible for providing documents requested
                                                                     solicitados por el contratista. Los siguientes son ejemplos de las
by the contractor. Some examples of items that may be needed
                                                                     cosas podrían necesitar como comprobantes y los documentos que
for proof and documents that can be used for proof are:
                                                                     pueden usarse como comprobantes:
Where Applicant Lives and Plans to Continue Living
                                                                     Lugar donde vive y planea seguir viviendo el solicitante
   o Possible Proof: Valid Texas Drivers License
                                                                         o Posibles comprobantes: licencia de conducir de Texas
   o Current voter registration
                                                                              válida
   o Rent or utility receipts for one month prior to the
                                                                         o Inscripción en el registro de votantes actual
        month of application
                                                                         o Recibos de renta o servicios públicos del mes anterior al
   o Motor vehicle registration
                                                                              mes de la solicitud
   o School records
                                                                         o Registro de automóvil
   o Medical cards or other similar benefit cards
                                                                         o Registros escolares
   o Property tax receipt
                                                                         o Tarjetas médicas o de otras prestaciones similares
   o Mail addressed to the applicant, his / her spouse, or
                                                                         o Recibo de impuestos sobre la propiedad inmobiliaria
        children if they live together
                                                                         o Correo dirigido al solicitante, su cónyuge o sus hijos si
   o Other documents considered valid by the contractor
                                                                              viven juntos
                                                                         o Otros documentos considerados válidos por el contratista
Applicant Income
    o Possible Proof: Pay check stubs
    o Pay checks                                                     Ingresos de los solicitantes
    o W-2 tax forms or income tax returns                                 o Posibles comprobantes: talones de cheque de paga
    o Sales records                                                       o Cheques de paga
    o Statements from employers                                           o Formularios W-2 de declaración de impuestos
    o Award letters                                                       o Registros de ventas
    o Legal documents                                                     o Declaraciones de empleadores
    o Statements from persons giving you money                            o Cartas de asignación de dinero
                                                                          o Documentos legales
Other Health Care Coverage                                                o Declaraciones de las personas que le dan dinero
    o Possible Proof: Award or claim letters
    o Insurance policies                                             Otra cobertura médica
    o Court documents                                                     o Posibles comprobantes: cartas de asignación de dinero o
    o Other legal papers                                                      reclamación
                                                                          o Pólizas de seguro
Information on social security numbers should be given if this            o Documentos de la corte
information is available. Information on sex (Male / Female) is           o Otros documentos legales
voluntary. These types of information will not affect your
eligibility.                                                         Debe darse la información sobre los números del Seguro Social si
                                                                     la información está disponible. La información sobre su sexo (si es
Applicant must give information about health care insurance and      hombre o mujer) es voluntaria. Estos tipos de información no
any other third party financially liable for health care services.   afectarán su derecho a participar.

                                                                     El solicitante debe dar información sobre seguros médicos y
                                                                     cualquier tercera persona económicamente responsable de los
                                                                     servicios médicos.
                                        DSHS FUNDING SOURCE - Worksheet
             Today’s Date                                            Client/Case #                                Type of Determination

                                                                                                                   New       Re-certification
           Applicant Name                                         Case Record Action                             Eligibility Effective Date
                                                                                                                      (MM-DD-YYYY)
                                             Approved          Presumptive     Supplemental        Denied
                      Eligibility Items                                              Documentation (if applicable)
Family Composition – Legal Responsibility
1.
2.

3.
4.
5.
.
6.
Residency – Must be physically present within the geographic                 Documentation of Residency (if applicable)
boundaries of Texas.


        Type of Income              Name of Member w/Income                   Documentation of Income (if applicable)

Gross Earned Income
Cash Gifts/Contributions
Child Support Income
Dividends/Interest/Royalties
Loans (Non-educational)
Lawsuit/Lump-sum Pymts.
Mineral Rights
Pensions/Annuities
Reimbursements
Social Security Payments
Unemployment Payments
VA Payments
Worker’s Compensation
Total Countable Income
Minus Dep Care/Child Sppt Pymt     -                 -
Net Countable Income                                                   FPL Used:             250%       200%          185%          150%
Other Benefits – Such as Medicaid, Medicare, CHIP, CIHCP, private health insurance, V.A., Tricare, etc.



Special Circumstances – Document any special circumstances as needed and applicable to this application



Co-Pay/Fees – DOCUMENT CO-PAY BELOW:


Eligible Household Member(s):
1.    BCCS       PHC          Title V/FP      2.      BCCS         PHC          Title V/FP    3.      BCCS         PHC          Title V/FP
   Title V/MCH          Title XX (only)            Title V/MCH           Title XX (only)           Title V/MCH           Title XX (only)
                  Epilepsy                                         Epilepsy                                        Epilepsy
4.    BCCS        PHC          Title V/FP     5.      BCCS         PHC          Title V/FP    6.     BCCS          PHC          Title V/FP
   Title V/MCH          Title XX (only)            Title V/MCH           Title XX (only)           Title V/MCH           Title XX (only)
                  Epilepsy                                         Epilepsy                                        Epilepsy
Provider-Staff Signature/Date:

                                                                                                                       EF05-13227
                                          DSHS FUNDING SOURCE – Worksheet Instructions

                                    Eligibility and Benefits by 2011 Federal Poverty Level (FPL)

 F                                                                                                                                      WIC           CHIP
 A                                               MEDICAID                                               CIHCP           PHC
 M                                                                                                                                     M&CH          CSHCN
 I        S
 L        I                                                                                                                         FP Title V,XX    BCCS
 Y                Medically       Children under 1 /                                                 21% FPL
          Z                                              Children 1 thru 5   Children 6 thru 18                      150% FPL                       EPILEPSY
                   Needy          Pregnant Females                                                  Min. Income                      185% FPL
          E                                                 133% FPL             100% FPL
                                      185% FPL                                                       Standard
                                                                                                                                                    200% FPL

               No Job    W/Job     No Job      W/Job    No Job     W/Job     No Job     W/Job     No Job    W/Job   N/A Statewide


     1         $104      $224     $1,679      $1,799 $1,207       $1,327      $908     $1,028     $191      $407      $1,362          $1,679        $1,815

     2          216      336       2,268      2,388     1,631      1,751     1,226     1,346      258       507        1,839           2,268         2,452

     3          275      395       2,857      2,977     2,054      2,174     1,545     1,665      325       608        2,317           2,857         3,089

     4          308      428       3,446      3,566     2,478      2,598     1,863     1,983      392       708        2,794           3,446         3,725

     5          357      477       4,035      4,155     2,901      3,021     2,181     2,301      458       807        3,272           4,035         4,362

     6          392      512       4,624      4,744     3,324      3,444     2,500     2,620      525       908        3,749           4,624         4,999

     7          440      560       5,213      5,333     3,748      3,868     2,818     2,938      592      1,008       4,227           5,213         5,635

     8          475      595       5,802      5,922     4,171      4,291     3,136     3,256      659      1,109       4,704           5,802         6,272

     9          532      652       6,391      6,511     4,595      4,715     3,455     3,575      726      1,209       5,182           6,391         6,909

     10         567      687       6,980      7,100     5,018      5,138     3,773     3,893      793      1,310       5,659           6,980         7,545
For each
additional       57                 589                  424                  319                  67                   478             589           637
 Member
                                                                                                                                Effective April 1, 2011

     o Family Composition Section – Enter the total number of family members in each category listed.         Total should include a person living alone or a
          group of two or more persons related by birth, marriage (including common-law), or adoption, which reside together and are legally responsible
          for the support of the other person. For example: If an unmarried applicant lives with a partner, ONLY count the partner’s income and children as
          part of the budget group IF the applicant and his/her partner have mutual children together. Unborn children should also be included.

     o Residency Section – Must be physically present within the geographic boundaries of Texas.
     o Income Section - Income may be either earned or unearned. If actual or projected income is not received monthly, convert it to a monthly amount
       using one of the following methods:
                 o Weekly income x 4.33
                 o Every two weeks x 2.17
                 o Twice a month x 2.0
       Dependent childcare expenses and legally obligated child support payments shall be deducted from total income in determining eligibility.
       Allowable deductions are actual expenses up to $200 per child per month for children under age 2 and $175 per child per month for children age 2
       to 12 or age 2 – 18 if child is disabled. The net countable income is used to determine eligibility based on the appropriate FPL percentage.
     o FPL Used – Determine the appropriate FPL used for each individual program.
     o Other Benefits Section – Provider staff shall document other benefits received by or denied to the applicant that are applicable to this application.
       An applicant or family member is eligible for the Medicare Prescription Drug Plan (Part D) if he/she is eligible and/or receives Medicare Part A
       and/or Part B benefits and shall be referred to this program for prescription drug benefits.
     o Special Circumstances – Provider staff may document any special circumstances not already noted using this section of the application, if
       applicable.
     o Co-Pay/Fees – Document co-pay/fees per program policies.

     o Eligible Household Members – Identify each eligible household member and program (via number association listed on Family
       Composition).
     o Provider-Staff Signature/Date – The provider staff that completes the eligibility determination process must sign and date this form.
                                                                                                                                    FORM 101
                                               STATEMENT OF APPLICANT’S RIGHTS AND RESPONSIBILITIES
                                              DECLARACIÓN DE LOS DERECHOS Y DEBERES DEL SOLICITANTE
By signing this application for assistance, I affirm the following:     Al firmar esta solicitud para recibir asistencia, yo afirmo lo siguiente:
The information on the application and its attachments is true          La información escrita en la solicitud y en sus anexos es verdadera y
and correct. This application is a legal document. Deliberately         correcta. Esta solicitud es un documento legal. El deliberadamente omitir
omitting information or giving false information may cause the          información o el proporcionar información falsa podría dar lugar a que el
Provider to terminate services to a member of my                        Proveedor cancele los servicios a uno de los miembros de mi hogar, de mi
household/family or me.                                                 familia o los míos propios.

If I omit information, fail or refuse to give information, or give      Si yo omito información, dejo de proporcionar o me niego a proporcionar
false or misleading information about these matters, I may be           información o; proporciono información falsa o engañosa acerca de estos
required to reimburse the State for the services rendered if I am       asuntos, podría requerírseme que reembolse al Estado el costo de los
found to be ineligible for services. I will report changes in my        servicios recibidos, si acaso se determina que no califico para los servicios.
household/family situation that affect eligibility during the           Yo reportaré los cambios en la situación de mi hogar, de mi familia, que
certification period (changes in income, household/family               afecten la elegibilidad durante el período de certificación (cambios en el
members, and residency).                                                ingreso, en los miembros del hogar, en la familia y, cambios de residencia.)

I authorize release of all information, including but not limited to,   Yo autorizo la divulgación de toda la información, incluyendo pero no
income and medical information, by and to the Texas Department          limitada a, el ingreso y a la información médica, de parte de y para, el
of State Health Services (DSHS) and Provider in order to                Texas Department of State Health Services (DSHS) [Departamento Estatal
determine eligibility, to bill, or to render services to my             de Servicios de Salud de Texas] y, al Proveedor para poder determinar la
household/family or me.                                                 elegibilidad, para poder cobrar o, proporcionar servicios en mi hogar, a mi
                                                                        familia o, a mí personalmente.

I understand I may be asked by Provider to provide proof of any         Entiendo y acepto que podría pedirme el Proveedor que proporcione
of the information provided in this application.                        comprobantes de cualquiera de la información proporcionada en esta
                                                                        solicitud.

Health insurance coverage, including but not limited to individual      La cobertura de seguro de salud, incluyendo pero no limitada a seguro
or group health insurance, health maintenance organization              para un individuo o seguro de salud para un grupo de personas; los de
membership, Medicaid, Medicare, Veterans Administration                 membresía proporcionados por organizaciones para el mantenimiento de la
benefits, TRICARE, and Worker’s Compensation benefits, must             salud [como HMO], Medicaid, Medicare; beneficios de la Veterans
be reported to Provider. Benefits from health insurance may be          Administration; de la TRICARE y Worker’s Compensation [beneficios de
considered the primary source of payment for health care                Compensación Laboral], deben ser reportados al Proveedor. Los
received. I hereby assign to Provider any such benefits. I also         beneficios provenientes de esos seguros de salud pudieran ser
assign payment for benefits and services received from and              considerados como la fuente principal de pago de la atención de salud
through Provider directly to the service providers.                     recibida. Por este medio yo, asigno al Proveedor cualquiera de dichos
                                                                        beneficios. También asigno el pago de los beneficios y servicios recibidos
                                                                        de parte de y, a través del Proveedor, directamente a los proveedores de
                                                                        servicios.
I understand that, to maintain program eligibility, I will be           Yo entiendo y acepto que, para mantener la elegibilidad para el programa,
required to reapply for assistance at least every twelve months.        se me va a requerir que vuelva a solicitar para recibir asistencia, por lo
                                                                        menos cada doce meses.
I am a bona fide resident of Texas or a dependent. I physically         Soy residente legítimo de Texas o bien, dependiente del territorio. Yo vivo
live in Texas, maintain living quarters in Texas, and do not claim      físicamente en Texas, mantengo residencia en Texas y, no afirmo ser
to be a resident of another state or country, or am a dependent of      residente de otro estado o país o bien, soy un dependiente de un residente
a bona fide Texas resident.                                             legítimo de Texas.

Some programs provide care through program-approved                     Algunos programas proporcionan atención a través de proveedores
providers. I understand that, to receive benefits from such             aprobados por los programas. Yo entiendo y acepto que, para recibir
programs, treatment must be received through those program-             beneficios de dichos programas, el tratamiento debe ser recibido a través
approved providers.                                                     de esos proveedores aprobados por el programa.

I understand that criteria for participation in the program are the     Yo entiendo y acepto que el criterio para la participación en el programa es
same for everyone regardless of sex, age, disability, race, or          el mismo para todos sin importar sexo, edad, discapacidad, raza o bien,
national origin.                                                        origen de nacionalidad.
I understand I have the right to file a complaint regarding the         Yo entiendo y acepto que tengo el derecho de registrar una queja con
handling of my application or any action taken by the program           relación al manejo de mi solicitud o con relación a cualquier acción tomada
with the HHSC Civil Rights Office at 1-888-388-6332.                    por el programa con HHSC Civil Rights Office de 1-888-388-6332.
I understand that I will receive written documentation concerning       Yo entiendo y acepto que recibiré documentación por escrito concerniente
the services for which my household/family or I is eligible or          a los servicios para los cuales mi hogar, mi familia o yo calificamos o,
potentially eligible.                                                   potencialmente lleguemos a calificar.
With few exceptions, you have the right to request and be               Tan solo por unas cuantas excepciones, usted tiene el derecho de solicitar
informed about information that the State of Texas collects about       y de ser informado sobre la información que el Estado de Texas reúne
you. You are entitled to receive and review the information upon        sobre usted. A usted se le debe conceder el derecho de recibir y revisar la
request. You also have the right to ask the state agency to             información al requerirla. Usted también tiene el derecho de pedir que la
correct any information that is determined to be incorrect. See         agencia estatal corrija cualquier información que se ha determinado sea
http://www.dshs.state.tx.us for more information on Privacy             incorrecta. Diríjase a http://www.dshs.state.tx.us para más información
Notification. (Reference: Government Code, Section 552.021,             sobre la Notificación sobre privacidad. (Referencia: Government Code,
522.023 and 559.004)                                                    sección 552.021, 522.023 y 559.004)
I understand and agree that the program does not provide                Entiendo y acepto que el programa no proporciona pago por la atención de
payment for inpatient care. I understand that I must make my own        pacientes internos. Entiendo y acepto que yo debo hacer mis propios
arrangement for hospital care and that I am responsible for the         arreglos de atención en el hospital y que yo soy responsable por el costo
cost of the care.                                                       de la atención.
Signature – Applicant / Firma – Solicitante              Date / Fecha   Provider Staff Signature                                              Date




                                                                                                                                   September 2011
                                                                                                                               FORM 102




                                Presumptive Eligibility - Title V and Primary Health Care
 Name/Nombre                                                         Home Telephone No./Teléfono de la casa
                                                                     (If no phone, give number of person who can reach applicant/ de no tener
                                                                     teléfono, proporcione el teléfono de la persona que pueda ponerse en contacto
                                                                     con el solicitante)


 Mailing Address (Street or P.O. Box)/Dirección Postal (Calle o      City/Ciudad                           State/Estado   ZIP/Zona Postal
 Apdo.)


 Home Address, if different from above. Domicillio particular, si es diferente a la dirección de arriba.




1. Are you or the person applying for services a resident of Texas?
   ¿Son residents de Texas, usted o la persona que solicita servicios?….……………………………..                                            Yes/Sí           No

2. How many family members live with you? (Count only applicant, spouse and children for whom applicant is
   legally responsible.)¿Cuántos miembros de la familia viven con usted? (Cuente únicamente al solicitante,
   esposo(a) y niños de los que el solicitante es legalmente responsable.) __________________________________

3. How much money (before deductions) does your family receive each month? ¿Cuánto dinero (antes de las
   deducciones) recibe su familia por mes? __________________________________________________________


I am in need of immediate medical care. To the best of my knowledge, I have no other way to receive medical
care and am applying for Presumptive Services. I understand that within 90 days following the delivery of
services, I will submit a completed application for eligibility determination. The above information is true,
correct, and complete to the best of my knowledge.

Yo estoy necesitando atención médica inmediata. En lo que a mí concierne carezco de cualquier otro medio para
recibir atención médica y estoy solicitando Presumptive Services [Servicios Condicionales.] Yo entiendo y acepto que
dentro de 90 días después de recibir los servicios yo entregaré una solicitud completamente llena, para que se lleve a
cabo la determinación de elegibilidad. La información arriba proporcionada es verdadera, correcta y completa según mi
leal saber y entender.

 Signature – Applicant / Firma – Solicitante                                          Date / Fecha



 Signature – Provider Staff / Firma – Oficinista                                      Date / Fecha




I was not able to complete the eligibility determination process for the Program. My appointment for returning
my complete application and interview is:
No me fue posible completar el proceso de determinación de elegibilidad para el P rograma. La cita para devolver mi
solicitud ya llenada y para la entrevista es

 Date and Time/ Hora y Fecha                                        Location and Phone/ Lugar y Teléfono




I understand this is my obligation for the services received.
Yo entiendo y acepto que esta es mi obligación por los servicios recibidos.

  EF21-11817
                                                                                                                                 September 2011
                                                                                                  FORM 102A
                                                                                                  INSTRUCTIONS




                                        Presumptive Eligibility Form
                                              Instructions

PURPOSE
 1. If applicant cannot fulfill application procedures AND applicant is in need of immediate medical services, the
     Presumptive Eligibility Form is to be completed. Additionally, a Statement of Applicant’s Rights and
     Responsibilities must be completed.
 2. To establish if applicant appears to be eligible for Title V and/or Primary Health Care.


PROCEDURE
When to Prepare
Complete for persons in medical need who appear to be eligible for Title V and/or Primary Health Care but time or
lack of materials prevent screening and eligibility determination.

Number of Copies
Complete an original and one copy.

Transmittal
Give a copy of the form to the applicant with an appointment time for application process. File original.

Form Retention
Keep the case record copy for three state fiscal years after services rendered.


DETAILED INSTRUCTIONS
Complete the date, name of applicant, name of legally responsible adult if applicant is a minor, address and
phone number where applicant (legally responsible adult) can be reached. Agency staff is responsible for
ensuring appropriate completion of the Presumptive Eligibility Form and a Statement of Applicant’s Rights and
Responsibilities.

 1. Verify the residency of applicant and mark yes or no. Refer to the policy manual for definition of residency.
 2. Enter the number of members in the immediate family. Refer to the policy manual for definition of family.
 3. Enter the gross monthly income of the immediate family. Refer to the policy manual for definition of income if
    applicant falls within Program guidelines.

The applicant appears to be potentially eligible for services on a Presumptive Eligibility basis if the applicant:
1. is a Texas resident, and
2. gross monthly family income (based on family size) falls at or below income guidelines.




NOTE:
If the contractor renders services and the above two criteria were not met, Title V and/or PHC will not reimburse.
If applicant does not meet these two criteria it is up to the Contractor to determine where and when services will
be provided. Although Title V and PHC are under strict eligibility guidelines, it is encouraged that an applicant's
medical needs be met quickly and appropriately using whatever resources are locally available.




                                                                                               September 2011
                                                                                                                          FORM 103
                       Notice of Eligibility/Aviso de Elegibilidad - Title V and Primary Health Care
Date/Fecha                                  Case No./ Número de caso                        Expiration Date/ Fecha de vencimiento


Office Address/ Dirección de la oficina                        Office Telephone/Teléfono de la oficina


Provider Staff Name/Nombre del trabajador



1. Your individual / family application for Title V / Primary Health Care is APPROVED / DENIED.
     Su solicitud individual / familiar para el Título V / Programa de Atención Médica Primaria ha sido APROBADA / NEGADA.

2. If approved, the following services will be provided beginning ______________________.
                                                                             (MM/DD/YYYY)
   Si tiene derecho, se ofrecerán los siguientes servicios a partir del ______________________.
                                                                             (mes/día/año)
                                              Date of Birth/
               Name/Nombre                      Fecha de                                    Services/Servicios
                                               nacimiento
a.

b.

c.

d.

e.


3. Your co-pay is $______________ for services and $______________ for prescriptions.

     Su copago es $______________ por servicios y $_______________ por recetas médicas.

4. You must notify this office as soon as possible of any changes in your situation such as changes in
   income, property, health insurance, family members or address. Usted tiene que avisar a esta oficina tan
   pronto sea posible de cualquier cambio en su situación como cambios de ingresos, propiedad, seguro medico,
   personas de la familia o dirección.

5. If a change occurs that makes you ineligible, and you fail to report the change as required, you may be
   responsible for payment of any medical services you receive after you become ineligible, or you may be
   subject to prosecution under the Texas Penal Code. Si ocurre un cambio que hace que pierda la
   elegibilidad y usted no informa del cambio como se exige, es posible que sea responsable de pagar cualquier
   servicio médico que reciba después de perder la elegibilidad, o puede ser que sea sujeto a enjuiciamiento bajo
   en Código Penal de Texas.

6. You are responsible for renewing your eligibility prior to your certification expiration date. A DSHS
   Funding Source - Application for Health Care Assistance must be completed and submitted within thirty
   (30)-days of your anniversary eligibility date. Assistance will be provided if needed. Usted es
   responsable de renovar su elegibilidad antes de la fecha de vencimiento de la certificación. Tiene que llenar y
   entregar un Screening and Eligibility Determination Form for Medical Services Assistance dentro de los treinta
   (30) días de la fecha de su aniversario. Recibirá ayuda si es necesario.

7. If not eligible, your application for Title V/Primary Health Care benefits has been denied due to:
   Si no tiene derecho, su solicitud para beneficios del Programa de Atención Médica Primaria/Title V se ha
   negado porque:




          If you believe this decision is not correct, you may request an appeal from this office. Si cree que esta
         decisión no está correcta, puede pedir una súplica de esta officina.

                                                                                                                     September 2011
                                                                                FORM 103A
                                                                                INSTRUCTIONS




                                   Notice of Eligibility Form
                                         Instructions


PURPOSE
 1. To notify Title V and/or Primary Health Care applicants that they are either eligible or not
    eligible for assistance.
 2. To notify Title V and/or Primary Health Care clients of their responsibilities to report
    changes in their situation and their liability if they fail to report changes.


PROCEDURE
When to Prepare
Complete form for individuals applying for Title V and Primary Health Care.

Number of Copies
Complete an original and one copy.

Transmittal
Face-to-face or mail form to the individual appl   ying for assistance. File c opy in the case
record.

Form Retention
Keep the case record copy for        three state fisca l years after eligibility be gins. However,
eligibility is valid for a maximum of twelve months.


DETAILED INSTRUCTIONS
Complete the information listed on the form.




                                                                              September 2011
                                                                                                                                Form 104

                                       PRIMARY HEALTH CARE PROGRAM
                                         REQUEST FOR INFORMATION
                                   PROGRAMA PRIMARIO de ASISTENCIA MEDICA
                                          SOLICITUD DE INFORMACIÓN


                                                                            Date/Fecha                     Case Record No./Núm de Caso



                                                                            Office Address and Telephone No./Oficina y Teléfono




Your application for assistance is not complete. To determine your eligibility, we need the following
additional information./Su solicitud de asistencia no está completa. Para determinar su elegi bilidad,
necesitamos la siguiente información.
  ONLY THE CHECKED BOXES APPLY TO YOU./SOLAMENTE LAS CASILLAS MARCADAS SE APLICAN A SU CASO.
   Mail Addressed to You or Another Household Member                Federal Income Tax Return
   Correo Dirigido a Usted o a Otra Persona de su Casa              Declaración de los Impuestos Federales Sobre los Ingresos
   Texas Driver’s License or Other Official Identification          Self-Employment Bookkeeping, Sales, Expenditure Records
   Licencia de Manejar de Texas u Otra Identificación Oficial       Comprobantes de Cuentas, Ventas, Gastos de Trabajo Independiente
   Voter Registration Card                                          Social Security Award Letter, Check, or Denial Notice
   Certificado de Registro Electoral                                Cheque de Seguro Socil o Carta Diciendo si se lo Van a Dar o No
   Notice of TANF, SNAP/ Food Stamps, or Medicaid Benefits          Disability Insurance Award Letter or Check
   Aviso de Beneficios de TANF,Estampillas para Comida o Medicaid   Cheque de Seguro por Incapacidad or Carta Diciendo que Van a Dárselo
   Paychecks or Paycheck Stubs                                      Unemployment Compensation Award Letter or Check
   Cheques de Paga o Talones de Cheques de Paga                     Cheque de Compensación de Desempleo o Carta Diciendo que Van a Dárselo
   Earnings Statement from Employer                                 Veterans Administration Award Letter or Check
   Verificación de Sueldo Preparada por el Empleador                Cheque de la Administración de Veteranos o Carta Diciendo que Van a Dárselo
   Worker’s Compensation Award Letter or Check                      Other Items
   Cheque del Seguro Obrero o Carta Diciendo que Van a Dárselo      Otra




PLEASE RETURN THE ITEMS CHECKED ABOVE BY:
HAGA EL FAVOR DE ENVIAR LOS DOCUMENTOS ENUMERADOS PARA EL:
If we do not receive the information we need and you do not contact me, I will assume that you do
not want assistance. Call me if you have any questions./ Si no recibimo s la i nformación que
necesitamos y usted no se comunica conmigo, supondré que usted no quiere asistencia. Si tiene algu na
pregunta, hábleme.



                      Signature/Firma:




                                                                                                                  September 2011
                                                                                                         Form 128
                                                                                                        Page 1 of 2

                             PRIMARY HEALTH CARE PROGRAM
                                EMPLOYMENT VERIFICATION



                                                              Date/Fecha               Case Record No./Núm de Caso



                                                              Office Address and Telephone No./Oficina y Teléfono




                                                               Fax:

Employee                                             Social Security Number




This individual is a member of a household applyi ng for health care assistance from the Primary
Health Care Program. To determine this household’s eli gibility, it is n ecessary to verify al l
earnings. Since this individual is/was/will be your employee, your help is needed.

Please completely and accurately provide the information requested on the back of this letter. If
a question does not apply, mark it N/A. After you complete t his form, give it to your employee,
mail it in the envelope provided, or fax it to the number listed above.

This information is needed by this date: ______________________. If you could send it before
this date, it would be most appreciated.

Thank you for helping. If you have questions, please feel free to call.


   I give my permission to release the information requested on this form.
   Yo doy mi permiso para que mi empleador dé la información que se pide en esta forma.



                                 Signature / Firma                                      Date / Fecha




Comments:




                                                                                              September 2011
                                                                                                                                   Form 128
                                                                                                                                  Page 2 of 2

                                                  EMPLOYMENT VERIFICATION
Employee Name (as shown on your records)



Employee Address – Street, City, State, ZIP (as shown on your records)



Is/was/will this person (be) employed by you?                                                          Is FICA or FIT withheld?


             Yes              No         If yes             Permanent              Temporary                      Yes               No

Rate of Pay                                                                   Average Hours per Pay Period     How often is employee paid?

                       Per         Per         Per         Per          Per
$                      Hour        Day         Week        Month        Job

On the chart below, list all wages received
by this employee during the months of:      _______________________________________________________
                                                                                                                        Other Pay *
                                     Date Employee                                                               (Bonuses, Commissions,
Date Pay Period Ended                                           Actual Hours            Gross Pay
                                   Received Paycheck                                                             Overtime, Pension Plan,
                                                                                                                   Profit Sharing, Tips)




                                                           * In Comments Section below, please explain when and how Other Pay is received.

Date Hired                  Date First Paycheck Received     If employee is/was on Leave Without Pay

                                                             Start Date:                               End Date:
If this person is no longer in your employ

Date Final Paycheck Received:                                Gross Amount of Final Paycheck: $
Is health insurance available?

                                                                                                   Enrolled for           Enrolled with
             Yes              No          If Yes, employee is                 Not Enrolled         Self Only              Family Members



Comments:


                   Signature and Title of Person Verifying This Information                                      Date

Company or Employer                    Address (Street, City, State, ZIP)                     Telephone Number (Include area code.)




                                                                                                                        September 2011
                                                                                                                                                       Form 149
                                                                                                                                                      Page 1 of 2
                                            STATEMENT OF SELF-EMPLOYMENT INCOME
                                         DECLARACIÓN DE INGRESOS DEL NEGOCIO PROPIO
                                        See Instructions on Page 2./Vea las Instrucciones en la página 2.

Case Record Name                                                                  Case Record Number




1. Name of Person Having Self-Employment Income/Nombre de la persona que tiene ingresos de negocio propio.



2. Give the number of months covered by this income statement.
   Dé el número de meses que cubre esta declaración de ingresos. .............................................................................

3. Describe what you did to earn this money./Describa lo que hizo para ganarse este dinero.




4. List your business expenses and income. IMPORTANTE: Attach receipts, invoices, or other verifying papers.
   Anote los gastos y ingresos de su negocio. IMPORTANTE: Adjunte recibos, facturas, u otros comprobantes.

    Date                   EXPENSES                           Amount                     Date                       INCOME                           Amount
   Fecha                    GASTOS                            Cantidad                   Fecha                    INGRESOS                           Cantidad

                                                        $                                                                                        $




                                 Total Expenses                                                                         SUBTOTAL                 $
                                 Total de Gastos        $                                       Enter expenses here and subtract.
                                                                                                    Anote el total de gastos y reste.            —

                                                                                    NET SELF-EMPLOYMENT INCOME
                                                                              INGRESOS NETOS DEL NEGOCIO PROPIO $
The above information is true, correct, and complete to the best of my knowledge. I understand that giving
false information to the provider could result in my being disqualified for fraud./Según mi leal saber y entender,
toda esta información es cierta, correcta y completa. Comprendo que si doy informa ción falsa al prove edo puedo ser
descalificado por fraude.


  Signature of anyone helping you to prepare this form / Date                               Signature / Firma                                    Date / Fecha
    Firma de la persona que le ayudó a llenar la forma / Fecha


                                                                                                                                         September 2011
                                                                                                          Form 149, Statement of Self-Employment Income
                                                                                                                                             Page 2 of 2
 If you or an y member of your household has a ny kind of self-                   Si usted u otra persona de su casa tiene algún tipo de ingresos de negocio
 employment income, fill out thi s form and attach it to y       our              propio, llene esta forma y adjúntela a su solicitud. En lugar de esta forma,
 application. You may attach a copy of the latest income tax forms                puede adjuntar una copia de la declaración de impuestos sobre ingresos
 in place of this form. If your accounting system is not the same as              más reciente. Si el sistema de co ntabilidad que usa no es igual al de esta
 this form, y ou may substitute a copy of your accounting                         forma, puede substituir la for ma con una c opia de su re gistro de
 statement. You must answer all questions and sign and date at                    contabilidad. Tiene que contest ar todas las preguntas y firmar y fechar la
 the bottom. Use additional sheets of paper if you need to.                       forma al final. Use hojas adicionales si las necesita. Firme y feche cada
 Sign and date each sheet. R emember, this is your sworn                          hoja. Recuerde que ésta es una declaración jurada. Tiene que lle var a la
                                                                                  entrevista: cuentas, recibos, cheques o talones de cheques y cualquier otra
 statement. You will need to bring with you to the i nterview: bills,
                                                                                  documentación que tenga del n egocio. El trabajador tendrá que verlos.
 receipts, checks or stubs, and any other business records you
                                                                                  Estos documentos le serán devueltos.
 have. Your worker will need to see them. Your records will be
 returned to you.                                                                 Ingresos del Negocio Propio. Este término se refiere al dinero que gana
                                                                                  cuando trabaja p or su propia cue nta. No es el dinero que r ecibe cuando
 Self-employment Income. This is any money you earn working                       trabaja para otra persona. Si tiene alguna duda, consulte con su
 for yourself. It is not money you earn working for someone else. If              trabajador de casos.
 you are in doubt, ask your caseworker.
                                                                                  Preguntas 1, 2, y 3. Estas preguntas no necesitan más explicación.
 Questions 1, 2, and 3. These questions are self-explanatory.
                                                                                  Pregunta 4. Apunte los ingresos y gastos de su negocio. En la s cajas del
 Question 4. List your business income and expenses. In the                       lado izquierdo de la forma, enumere los      gastos de su negocio (vea la
 boxes on the lef t side of the fo rm, list y our business expenses               información abajo). Ponga la fecha en que pagó los gastos y la c antidad
 (see the information below). Write in the dates you paid the                     de cada gasto. Sume las cantidades y ponga el total en la caja que dice
 expenses and the amount of each expense. Add the amou nts,                       "total de gastos del negocio propio". En las cajas a la derecha de la
 and enter your total in the box "total self-employment expenses."                forma, enumere los ingresos (vea la información abajo). Ponga l a fecha
 In the boxes on the right side of the form, list y our income (see               en que recibió cada ingreso, la f uente del ingreso y la cantidad. Sume las
 the information below). List the dates you received the income ,                 cantidades y ponga el total en la caja que dice "total de ing resos del
 your sources of income, and the amounts. Add the amounts, and                    negocio propio". Reste los gastos del total de ingresos del negocio propio
 enter your total in the b ox "total self-employment income."                     y anote sus "ingresos netos del negocio propio".
 Subtract your expenses from your total self-employment income,                   Los gastos son los costos de un negocio. Algunos ejemplos de posibles
 and enter your "net self-employment income."                                     gastos son: provisiones, reparaciones, renta, servicios públi cos, semilla,
 Expenses are your costs of doing business.             Examples of               forraje, seguro del negocio, licencia s, cuotas, pagos del capital de
                                                                                  préstamos para propiedades que generan ingresos, compras de bienes de
 expenses are supplies, repairs, rent, utilities, seed, feed, business
                                                                                  capital (como bienes raíces, equipo, maquinaria y otros bienes duraderos y
 insurance, licenses, fees, pa yments on p rincipal of loans fo r
                                                                                  mejoras de bie nes de capital), su aportación al seguro social de las
 income-producing property, capital asset purchases (such as real
                                                                                  personas que trabajan para usted y sueldos (pero no los que se pa ga a sí
 property, equipment, machinery, and other du rable goods and
                                                                                  mismo). Si declara el costo de sueldos, ponga el nombre de cada persona
 capital asset im provements), your social security contribution fo r             y la cantidad que le pagó a cad a quien. Si tien e cualquier ot ro tipo de
 people who worked for you, and labor (not salaries you pa y                      gastos del negocio, asegúrese de anotarlos y poner la fecha en que los
 yourself). If you claim labor costs, list each       person and t he             pagó.
 amount you paid them. If y ou have any other kinds of business
                                                                                  No puede declarar:
 expenses, be sure to list them and the date they were paid.
                                                                                  • El pago de la renta, la hipoteca, los impuestos o los servicio s públicos
 You may not claim:                                                                 del negocio si lo opera de su casa (a no ser que estos costos son aparte
 • Rent, mortgage, taxes, or utiliti es on your business if it                      de los costos de la casa);
    operates out of your home (unless these costs a re separate                   • El costo de artículos que com     pra para el negocio pero que usa
    from the costs of your home);                                                   personalmente;
 • Cost of goods you buy for the business but use yourself;                       • La pérdida neta del negocio de un periodo anterior; and
 • Net business loss from a prior period and                                      • La depreciación.
 • Depreciation.
                                                                                  Si tiene alguna duda, lleve comprobantes del gasto y consulte con el
 If you are in do ubt, bring pr oof of the exp ense and ask your                  trabajador.
 worker.
                                                                                  Los ingresos son, entre otros, el dinero d e ventas, el ingreso de caja, las
 Income includes mone y from sales, cash r eceipts, crops,                        cosechas, las comisiones, las rentas, las cuotas o cualquier cosa que hace
 commissions, leases, fees, or whatever you do or sell for money.                 o que vende por dinero. Si uste d tiene cualquier otro tipo d e ingresos del
 If you have any other kind of inc ome from your business, be sure                negocio, asegúrese de anotarlo. No olvi de poner las fechas en que recibió
 to list it. Be sure to list the dates income was received.                       el ingreso.
 Who must sign. The form mu st be signed by the applicant,                        Quién debe firmar. El solicitante, su cónyuge o su representante autorizado
 spouse, or aut horized representative. Anyone may help you                       para firmar la fo rma. Cualquier persona puede ayudarle a llenar la forma,
 complete the for m, but that person must also sign and dat e the                 pero esa person a también tiene que firmar y poner le fecha e n la forma.
 form. Ask your worker if anyone else needs to sign the form.                     Consulte con el trabajador para saber si alguien más tiene que firmar.
With a few exceptions, you have the right to request and be informed about the information that the county obtains about you. You are entitled to receive and
review the information upon request. You also have the right to ask the county to correct information that is determined to be incorrect (Government Code,
Sections 552.021, 552.023, 559.004). To find out about your information and your right to request correction, please contact your local county office. / Con algunas
excepciones, usted tiene el derecho de saber qué información obtiene sobre usted el condado de pedir dicha información. Si desea recibir y estudiar la información, tiene el
derecho de solicitarla. También tiene el der echo de pedir que el condad corrija cualquier información incorrecta (Código Gubernamental, Secciones 552.021, 552.023,
559.004). Para enterarse sobre la información y el derecho de pedir que la corrijan, favor de ponerse en contacto con la oficina local del condado.




                                                                                                                                                  September 2011
                                                                                 FORM 200




                              PHC - 200 MONTHLY REPORTING FORM


                                                        Report or Amended
Contractor: ____________________________________        Report for (Month/Year) ______
Location:     ____________________________________
Phone number: _________________________________
I. TOTAL NUMBER OF UNDUPLICATED CLIENTS DETERMINED ELIGIBLE AND
PROVIDED A PRIMARY CARE SERVICE: _______________(must match # in Box #20 of voucher)


TOTAL NUMBER OF INELIGIBLE APPLICANTS:_______________


II. COSTS OF PHC FUNDED SERVICES DURING THIS REPORTING MONTH
Diagnostic and Treatment                   1
Emergency Services                         2
Family Planning Services                   3
Preventive Health Services                 4
Health Education Services                  5
Laboratory/X-Ray Services                  6
Nutrition                                  7
Health Screening                           8
Dental                                     9
Transportation                             10
Prescription Drugs                         11
Social Services                            12
Other Optional Services                    13
Administrative Costs                       14

Total (1 - 14= 15)
(Amount of Requested Reimbursement)        15   $   -




     Signature of Person Submitting Form                              Date



                                                                             September 2011
                                                                    FORM 200A
                                                                  Monthly Report
                                                                 INSTRUCTIONS

PURPOSE                                      II. Cost of Services During Month: Enter
Use to provide information to DSHS           the dollar amount spent/paid in the
about:                                       calendar report month for each of the
 PHC caseload and                           categories in Items 1-14. List only
 Contractor’s expenditure levels by         expenditures that are applicable to
   PHC service.                              DSHS PHC funds and services.

PROCEDURE                                    Item 1-13 enter costs for providing the
Form 200 must be completed and               services associated with providing direct
submitted to DSHS PCG in Austin within       patient care; costs may include salaries of
5 working days of the month following the    individuals providing healthcare services,
report month.                                medical supplies and equipment,
                                             contractor costs, etc.
Fax or email Form 200 to DSHS PCG
at 512/458-7713 /                            Item 2 enter costs associated with
(FY11PHCReports@dshs.state.tx.us)            providing emergency services, however,
                                             DO NOT count costs associated with
                                             hospital emergency room costs.
DETAILED INSTRUCTIONS
General Information:                         Item 3 enter costs associated with
Contractor: Name of contractor on DSHS       pregnancy tests, physicals, contraceptive,
contract                                     etc.
Report or Amended Report: Enter month
and year the expenditures are spent/paid.    Item 4 enter costs associated with
                                             immunizations, annual Pap smears, routine
Any amendments to a report should be         eye exams, etc.
marked “Amended” and submitted on
the Form 200. The amended item(s)            Item 5 enter associated with any other
should be circled.                           costs such as, education materials, etc.

I. Caseload Data.                            Item 6 same as noted in item 1.

Total number of unduplicated clients         Item 7-13 enter the costs associated with
served. Enter the total number of all        each service.
eligible individuals that were provided
any of the six priority and/or optional      Item 14 administrative costs may include
services (i.e. presumptive, full-service,    costs not associated with direct patient
supplemental). Regardless of the number      care, such as salaries for non-healthcare
of PHC services or visits, only count the    individuals, administrative supplies,
individual once. DO NOT count that           screening and eligibility and other costs not
individual again during the report month     listed in Items 1-13.
or in any other month the remainder of
the fiscal year. If an eligibility           Item 15 enter the total of 1-14. The Total
determination was made, but no PHC           costs listed in Item 15 should equal the
service was given, do not count until a      total requested reimbursement amount on
PHC service is provided. This number         the monthly voucher. (See PHC State of
must match number reported on voucher.       Texas Purchase Voucher {FORM B-13}.)
Total number of ineligible applicants:
Enter the total number of individuals were
determined ineligible for PHC services.




                                                                    September 2011
                                                                                                FORM 300




                                    PRIMARY CARE ANNUAL REPORT

Contractor Name:
Contact Name
Contact Phone:
Fiscal Year

1. Total number of unduplicated DSHS PHC clients served this fiscal year: _______

2. Number of unduplicated DSHS PHC clients served by age and gender:

Age                                 Number of Males                     Number of Females
0 to 17 years
18 – 64 years
65 years +
TOTAL                                                               0                       0

3. Number of unduplicated DSHS PHC clients served by race/ethnicity:

Race                                                                    Number Served
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Unknown
TOTAL                                                                                       0

Ethnicity                                                               Number Served
Hispanic or Latino
Not Hispanic or Latino
TOTAL                                                                                       0

4. Number of unduplicated DSHS PHC clients served by citizenship:

Citizenship                                                             Number Served
US Citizens or legal Residents
Non-citizens
TOTAL                                                                                       0




                                                                                            September 2011
                                                                                                    FORM 300


5. Number of unduplicated DSHS PHC clients served according to income levels based on Federal
Poverty Level (FPL):

Percent of FPL                                                      Number Served
150 - 101%
100 - 51%
 50 - 22%
 21 - 0%
TOTAL                                                                                           0

6. Number of unduplilcated DSHS PHC clients by type of service:

Services                                                            Number Served
Full-services
Presumptive services only
Supplemental services
TOTAL                                                                                           0

7. a. Number of counties in DSHS PHC service area:

7. b. Number of unduplicated DSHS PHC eligible clients served by county of residence:

County Name                                                         Number of Clients




8. List the top five diagnoses of unduplicated DSHS PHC clients:

1
2
3
4
5




                                                                                                September 2011
                                                                                                            FORM 300




9. List the number of unduplicated clients to be served on the FY 12 Contract Performance Measure
____________.
 If the FY 12 Performance Measure was not met, provide an explanation.




10. Program accomplishments: In narrative form, highlight accomplishments of your DSHS PHC
project in providing primary health care sevices to unduplicated PHC clients during this fiscal year.




                                                                                                        September 2011
                                                                                 FORM 300A
                                                                        PHC-300 Annual Report
                                                                              INSTRUCTIONS

PURPOSE                                            NOTE: The number listed under TOTAL
Use to provide information to TDSHS about:         in 1, 2, 3, 4, 5, and 6 should be the same
• PHC demographic information                      number. Each total should equal the
                                                   unduplicated client count as listed in Item 1.
PROCEDURE
Form 300 must be completed and submitted to        Item 7: List the counties that are in your
                             th
TDSHS PHC in Austin by the 60 day of the           project’s service area. Next to county name,
following fiscal year.                             list the number of PHC clients served
                                                   according their county of residence. The total
Fax the Form 300 to PCG at 512/776-7713            number of clients served for all counties
or email                                           should equal the unduplicated client count in
PrimaryHealthCare@dshs.state.tx.us                 Item 1.

DETAILED INSTRUCTION                               Item 8: List the top five health care problems
                                                   most frequently encountered, with number
Item 1: Enter the total number of unduplicated     one being the most frequent.
PHC clients who received a PHC service this
year. Do not count individuals more than
once regardless of the number visits or            Item 9. Provide the number of unduplicated
services.                                          DSHS clients that were listed for FY 12
                                                   contract performance measure. If you were
Item 2: Enter the total unduplicated client
                                                   unable to serve the number listed, please
count served by age and gender.
                                                   provide an explanation.
Item 3. List the total unduplicated client count   Item 10: Write a summary of PHC program
served by race and by ethnicity. The               objectives or accomplishments achieved in
“unknown” category is for those clients who        the fiscal year.
did not specify or no information is available.
The total for race should equal the total for
ethnicity.

Item 4. List the total unduplicated client count
served by citizenship status. U.S. citizens or
Legal Residents are born in the U.S. or have
documentation for legal residency at the time
services are provided. Non-citizens are those
individuals not born in the U.S. and have no
documentation of legal residency. ( Accept
self declaration as listed on the Screening and
Eligibility Application.)

Item 5. List the total unduplicated client count
by poverty level.

Item 6. List the total unduplicated client count
by PHC eligibility status. Full-service = PHC
Clients with no other payment source;
Supplemental = clients that have another
source of payment; and Presumptive =
Individuals receiving immediate PHC services
but are potentially eligible for another payment
source such as Medicaid, Medicare, etc. Only
count these individuals in one of the above
eligible categories.


                                                                                September 2011
DSHS Form B-13
                                                                                      STATE OF TEXAS
                                                                                 PURCHASE VOUCHER Page                          of
                                                                                                    WP5.1 (9/93)


 1. Archive reference number                     2. Agency No.         3. Agency Name                                                                                       4. Current document number
                                                 537                                    TEXAS DEPARTMENT OF STATE HEALTH SERVICES
                                                 5. Effective date     6. DOC date             7. Due date                                      8. Doc Agency
                                                                                                                                                      537
 9.Payee identification number                   10. PDT               11. PCC
                                                                                               12. Requisition number        PO #                                           13. Document amount      $
 14. Payee name/address                                                15. GSC order number                            17. AGENCY USE

                                                                                                                        FUND          BUDGET          CAT.         SERV DATE
                                                                       16. Lease number
                                                                                                                          General       or Program          Activity Code



      18.               Ref Doc           SFX               M            TC                 Index                   PCA                AY             COBJ             AOBJ                      Amount             R
     SFX
     001
                         APPN             Fund         NACUBO           Grant               Grant                  Project            Project            Contract number                        Multipurpose code
                                                       Sub-Fund        number             year/phase               number             phase

                     Invoice number                                  Description                                                     AGENCY USE

      18.               Ref Doc           SFX               M            TC                 Index                   PCA                AY             COBJ             AOBJ                      Amount             R
     SFX
     002
                         APPN             Fund         NACUBO           Grant               Grant                  Project            Project            Contract number                        Multipurpose code
                                                       Sub-Fund        number             year/phase               number             phase

                     Invoice number                                  Description                                                     AGENCY USE

      18.               Ref Doc           SFX               M            TC                 Index                   PCA                AY             COBJ             AOBJ                      Amount             R
     SFX
     003
                         APPN             Fund         NACUBO           Grant               Grant                  Project            Project            Contract number                        Multipurpose code
                                                       Sub-Fund        number             year/phase               number             phase

                     Invoice number                                  Description                                                     AGENCY USE



 19. SER/DEL DATE                     20. DESCRIPTION OF GOODS OR SERVICES                                                          21.              22. UNIT PRICE                     23. AMOUNT
                                                                                                                                    QUANTITY


                                      Reimbursement for services as specified in the contract                                                               Monthly                     $
                                      between the Texas Department of State Health Services                                                                 Expenses
                                      and
                                                                                                                                                          Less                          -
                                                                                                                                                     Program Income
                                      Program: CHS/PHC
                                      Contract Term: 9/1/08 thru 8/31/09                                                                                    Less                        -
                                      DSHS Doc #2009-                                                                                                      Advance
                                      Type of Entity:                                                                                                     Repayment

                                                                                                                                                            Less Non                    -
                                                                                                                                                             DSHS
                                      Total number of unduplicated clients determined                                                                       Funding
                                      eligible and provided a primary care service for this
                                      month: _____________ (This number must match the                                                                    Total                         $
                                      number reported on corresponding PHC-200 Report.)                                                              Reimbursement


 24. Contact name                                                                    Phone (Area code and number)                                    25. Entered by




 26. I approve this voucher for payment. The above goods or services correspond in every particular with the contract under which they were purchased. The invoice
 for the goods or services is correct. This payment complies with the General Appropriations Act.
 Approved                                                                                                                    Phone (Area code and number)                               Date
 sign here <
DSHS Form B-13
                                                                                    STATE OF TEXAS                                                                 EXAMPLE ONLY
                                                                                 PURCHASE VOUCHER Page                          of
                                                                                                    WP5.1 (9/93)


 1. Archive reference number                     2. Agency No.         3. Agency Name                                                                                       4. Current document number
                                                 537                                    TEXAS DEPARTMENT OF STATE HEALTH SERVICES
                                                 5. Effective date     6. DOC date             7. Due date                                      8. Doc Agency
                                                                        Submit Date                                                                   537
 9.Payee identification number                   10. PDT               11. PCC
                                                                                               12. Requisition number        PO #0000123456                                 13. Document amount      $12,345.67
 12345678901234
 14. Payee name/address                                                15. GSC order number                            17. AGENCY USE
 Contractor Agency Name
                                                                                                                        FUND          BUDGET          CAT.         SERV DATE
 Street/P.O. Box Address as set up with Comptroller
 City, State 12345-1234                                                16. Lease number
                                                                                                                          General       or Program          Activity Code



      18.               Ref Doc           SFX               M            TC                 Index                   PCA                AY             COBJ             AOBJ                      Amount             R
     SFX
     001
                         APPN             Fund         NACUBO           Grant               Grant                  Project            Project            Contract number                        Multipurpose code
                                                       Sub-Fund        number             year/phase               number             phase

                     Invoice number                                  Description                                                     AGENCY USE

      18.               Ref Doc           SFX               M            TC                 Index                   PCA                AY             COBJ             AOBJ                      Amount             R
     SFX
     002
                         APPN             Fund         NACUBO           Grant               Grant                  Project            Project            Contract number                        Multipurpose code
                                                       Sub-Fund        number             year/phase               number             phase

                     Invoice number                                  Description                                                     AGENCY USE

      18.               Ref Doc           SFX               M            TC                 Index                   PCA                AY             COBJ             AOBJ                      Amount             R
     SFX
     003
                         APPN             Fund         NACUBO           Grant               Grant                  Project            Project            Contract number                        Multipurpose code
                                                       Sub-Fund        number             year/phase               number             phase

                     Invoice number                                  Description                                                     AGENCY USE



 19. SER/DEL DATE                     20. DESCRIPTION OF GOODS OR SERVICES                                                          21.              22. UNIT PRICE                     23. AMOUNT
                                                                                                                                    QUANTITY


 Month & Year of                      Reimbursement for services as specified in the contract                                                               Monthly                     $12,895.67
 services                             between the Texas Department of State Health Services                                                                 Expenses
                                      and (Contractor Agency Name).
                                                                                                                                                          Less                          -      300.00
                                                                                                                                                     Program Income
                                      Program: CHS/PHC
                                      Contract Term: 9/1/08 thru 8/31/09                                                                                     Less                       -         0.00
                                      DSHS Doc #2009-123456-123                                                                                            Advance
                                      Type of Entity: University, Gov, Non-Profit, etc                                                                    Repayment

                                                                                                                                                            Less Non                    -      250.00
                                                                                                                                                             DSHS
                                      Total number of unduplicated clients determined                                                                       Funding
                                      eligible and provided a primary care service for this
                                      month               . (This number must match the                                                                   Total                         $12,345.67
                                      number reported on corresponding PHC-200 Report.)                                                              Reimbursement


 24. Contact name                                                                    Phone (Area code and number)                                    25. Entered by
 Person to be contacted when questions arise                                         Contact person’s phone and
                                                                                     extension

 26. I approve this voucher for payment. The above goods or services correspond in every particular with the contract under which they were purchased. The invoice
 for the goods or services is correct. This payment complies with the General Appropriations Act.
 Approved                                                                                                                    Phone (Area code and number)                               Date
 sign here <
                                                                                                                                                         Page 1


                      B                                        C                  D                           E                                 F


1                                 DEPARTMENT OF STATE HEALTH SERVICES
2
3                                                                  FINANCIAL STATUS REPORT
4                                                                               Form 269A
5 1100 West 49th Street                                                                                                        Austin, Texas 78756-3199
6              Contractor Name:                                                                 DSHS Program:
7                   Payee Name:                                                                      DSHS Document #           Year      Attachment #
8                         Address:
9                         Address:                                                              Contract Term: ( Month / Day / Year ):
10                   City, ST, Zip:                                                             from:                          to:
11      Payee Vendor ID No.:                                                                        Cash                              Accrual
12           Final Report?                                                                      Period Covered by this Report:
13                     PO Number:

14              BUDGET                              APPROVED                CURRENT PERIOD              CUMULATIVE                   BUDGET BALANCE
15           CATEGORIES                               BUDGET                    Col 1                       Col 2                          Col 3
16                     SALARIES                                                                                                 $                         -
17       FRINGE BENEFITS                                                                                                                                  -
18                         TRAVEL                                                                                                                         -
19                  EQUIPMENT                                                                                                                             -
20                     SUPPLIES                                                                                                                           -
21            CONTRACTUAL                                                                                                                                 -
22                           OTHER                                                                                                                        -
23              SUB-TOTAL                   $                       -   $                   -    $                     -        $                         -
24                        INDIRECT                                                                                                                        -
25                           TOTAL $                                -   $                   -    $                     -        $                         -
26                        LESS:              PROGRAM INCOME                                 -
27                                         NON-DSHS FUNDING                                                            -
28                  SUBTOTAL:                          DSHS SHARE                                                      -
     ADVANCE:
29   Received (Col1) - Repaid (Col 2) = Balance Owed (Col 3)            $                   -    $                     -        $                         -
30            REIMBURSEMENTS (net of advances)                                                  $                      -
31                 Prepared by:

32                     Title:                                                        Telephone #:
     CERTIFICATION: I certify to the best of my knowledge and belief that this report is correct and complete and
33   that all outlays and unliquidated obligations are for the purposes set forth in the award documents.

34   Name of Authorized Certifying Official:                                                                   Telephone #:

35
                                                                                                                      Fax #:

36   Title of Certifying Official:                                                                          Date Submitted:

37                                                                                                         FSR Receipt Date:


           9/1/2011                                                                                                    33-Financial Status Report 269a
APPENDICES
                       The Primary Health Care Program may be contacted at:

                              Texas Department of State Health Services
                                     Community Health Services
                                        Primary Care Group
                                       1100 West 49th Street
                                     Austin, Texas 78756-3168
                                       Phone: (512) 776-7111
                                        Fax: (512) 776-7713

                                         www.dshs.state.tx.us/phc

Jan Maberry, Group Manager                          Gina Baber, Program Specialist
(All aspects of the Program)                        (Program Lead )
Ext: 7728                                           Ext: 2023
E-mail: jan.maberry@dshs.state.tx.us                E-mail: gina.baber@dshs.state.tx.us

Carolyn Wachel, Program Specialist                  Karen Gray, Program Specialist
(Policy, Desk Reviews and Reports))                 (PHC Eligibility Training)
Ext: 2141                                           Ext: 2752
E-mail: caroly.wachel@dshs.state.tx.us              E-mail: karen.gray@dshs.state.tx.us

Sheila Rhodes, RN                                   Jim Conditt, Program Specilaist
(Region 1 – Contract Coordinator)                   (Policy and Desk Reviews)
Phone: (806) 783-6485 / Fax: (806)783-6435          Ext: 3529
E-mail: sheila.rhodes@dshs.state.tx.us              E-mail: jim.conditt@dshs.state.tx.us

Jamie Moore, RN                                     Chrysanne Randal, RN
(Region 1 – Contract Coordinator)                   (Region 2/3 – Contract Coordinator)
Phone: (806) 655-7151 X1113 / Fax: (806) 655-7159   Phone: (940) 888-8019 / Fax: (940) 888-3364
E-mail: jamie.moore@dshs.state.tx.us                E-mail: chrysanne.randal@dshs.state.tx.us

Laticcia Riggins                                    Lucille Coggins, RN
(Region 2/3 – Contract Coordinator)                 (Region 2/3 – Contract Coordinator)
Phone: (817) 264-4658 / Fax: (817)264-4555          Phone: (817) 573-8186 / Fax: (817) 578-3310
E-mail : laticcia.riggins@dshs.state.tx.us          E-mail: lucille.coggins@dshs.state.tx.us

Della Mendez                                        Waseem Ahmed
(Region 4/5N – Contract Coordinator)                (Region 6/5S – Contract Coordinator)
Phone: (903) 533-5334 / Fax: (903) 533-5367         Phone: (713) 767-3011 / Fax: (713)767-3408
E-mail: della.mendez@dshs.state.tx.us               E-mail: waseem.ahmed@dshs.state.tx.us


Ngozi Adimora, RN                                   Chesca Thurman
(Region 6/5S – Contract Coordinator)                (Region 7 – Contract Coordinator)
Phone: (713) 767-3014 / Fax: (713) 767-3408         Phone: (254) 771-6764 / Fax: (254) 778-6819
E-mail: ngozi.adimora@dshs.state.tx.us              E-mail: chesca.thurman@dshs.state.tx.us




                                                                                   September 2011
Pam Celaya-Flores                              Iva Martinez, RN
(Region 9/10 – Contract Coordinator)           (Region 9/10 – Contract Coordinator)
Phone: (432) 837-3877 / Fax: (432) 837-5523    Phone: (915) 834-7798 / Fax: (915) 834-7598
E-mail: pam.flores@dshs.state.tx.us            E-mail: iva.martinez@dshs.state.tx.us

Anna Weaver                                    Lupita Cazares, RN
(Region 11 – Contract Coordinator)             (Region 11 – Contract Coordinator)
Phone: (956) -421-5578 / Fax: (956) 444-3251   Phone: (956) 423-0130 X549 / Fax: (956) 444-3216 or 3299
E-mail: anna.weaver@dshs.state.tx.us           E-mail: mariaG.cazares@dshs.state.tx.us




                                                                              September 2011
                                                                             APPENDIX B


RESOURCES


DSHS Standards and Policy

More information on department-wide standards and policy for contractors may
be found on the Quality Management Branch website:

http://www.dshs.state.tx.us/qmb/default.shtm


Enabling Legislation

Enabling PHC legislation and Texas Administrative Code Rules may be found at
the following web site locations:

Texas Administrative Code:
http://info.sos.state.tx.us/pls/pub/plsql/readtac$ext.ViewTAC?tac_view=4&ti=25&pt=1&ch=39

Texas Health and Safety Code:
http://www.capitol.state.tx.us/statutes/hs.toc.htm




                                                                           September 2011

				
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