
Owing service(s) I am contracting to provide: Community Living Assistance and Support Services (CLASS) Day Activity and Health Services (DAHS) Medically Dependent Children Program (MDCP) Primary Home Care/Family Care/Community Attendant Services (PHC/FC/CAS) Signature – Authorized Representative Name of Authorized Representative (Type or Print) Date .
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How to fill out the TX 5872 online
Filling out the TX 5872 form can be straightforward when you follow the right steps. This guide aims to provide you with clear instructions to successfully complete the certification required for specific community service programs.
Follow the steps to complete the TX 5872 form online.
- Click the ‘Get Form’ button to obtain the TX 5872 form and open it in the online editor.
- Begin by entering the legal name of the entity in the designated field. Ensure that the name is typed accurately to reflect the official registered name.
- Next, carefully read through the Pre-Application Orientation Guide. This information is crucial as it relates to the service(s) you are contracting to provide.
- In the section for services, check all applicable boxes for the services you intend to provide. The options include Community Living Assistance and Support Services (CLASS), Day Activity and Health Services (DAHS), Medically Dependent Children Program (MDCP), and Primary Home Care/Family Care/Community Attendant Services (PHC/FC/CAS).
- Locate the signature field designated for the authorized representative. This individual must sign the form, certifying that they have completed the necessary steps and reviewed the guide.
- Type or print the name of the authorized representative in the given space. Ensure this name corresponds accurately with the person who is signing.
- Finally, add the current date in the designated section. Make sure this date is accurate as it signifies when the certification was completed.
- Once all fields are accurately filled out, you can choose to save the changes, download the form, print it, or share it as required.
Complete your TX 5872 form online today for a streamlined application process.
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