Get Community Services Contract Application Addendum C Emergency Response Services. Form 3681-c - Dads

This guide provides detailed instructions on how to complete the Community Services Contract Application Addendum C Emergency Response Services, Form 3681-C - Dads. Whether you are a first-time user or need a refresher, this step-by-step approach will help you ensure a thorough and accurate submission.

Follow the steps to successfully complete the form online.

1. To begin, click the ‘Get Form’ button to obtain the Community Services Contract Application Addendum C Emergency Response Services Form 3681-C - Dads. This will allow you to access the form in your editor.
2. In Section 1, Legal Entity Information, fill out the required fields including the name of the legal entity, Doing Business As (if applicable), Taxpayer Identification Number, National Provider Identifier, Base Station Physical Address, and DADS Region.
3. Proceed to Section 2, Service Area and Rate. List the county or counties you intend to serve. If covering all counties in the indicated region, select 'All Counties.' Also, propose a rate and indicate if you provide services to private-pay customers. If applicable, detail the fees for private pay rates.
4. Continue to Section 3, Licensure. Address whether the legal entity is subject to licensure. If yes, specify the source and type. If no, indicate the basis for exemption, and state if subcontractors are used to provide services.
5. Next, fill out Section 4, Subcontractor Information. Provide the legal names, service types, Taxpayer Identification Numbers, and licensure status for all subcontractors involved. Attach relevant agreements and licenses.
6. In Section 5, Assurances, confirm the legal entity's emergency response monitoring capability and provide details about the responsible individual and their contact information.
7. Finally, complete Section 6, Legal Entity Certification, by certifying the truthfulness of the provided information. Ensure to include the signature of an authorized representative, their printed name, date, and title.
8. Once all sections are accurately filled out, save your changes. You may also download, print, or share the completed form as necessary.

Complete your documents online today to ensure timely submission.