Independent Contractor Information

Send all the required information and Contract Information Form to Peggy Bagley, Unit #177

Submit the forms the Contractor filled out and using the information submitted a contract will be developed with the following steps:

  • All credentials verified by Contract Management.
  • All registry checks made by Contract Management.
  • Contract Management will notify Human Resources of Contractor and receive individualized training requirements. This information will be sent to Program Manager / Supervisor and inserted into Contract.
  • Contract Management will type up contract and have it approved and signed by the Executive Director.
  • Contract Management mails out two originals of the contract for Contractor’s signature;
  • Contractor returns one of the signed contracts back to Contract Management and keeps the other contract for their files.

Upon completion of the above, Peggy Bagley will notify the Program Manager / Supervisor and Human Resources to schedule training.

Contractor cannot start providing services until:

  1. A signed contract is received by the Contract Office or is covered by an amendment in an existing contract; AND
  2. All required training is completed.

Required Information Needed for Contract Development: This is found on the Intranet under Forms: Contract Development and on the Internet under Volunteer/Contractor

  1. Application for Contract Personnel
  2. W-9 Form (Taxpayer Information Number)
  3. Copy of Credentials:
  4. Physicians/Nurse Practitioners
  5. A copy of document issued by the University granting their degree.
  6. A copy of certification from the institution providing residency.
  7. A current copy of a license to practice medicine in Texas issued by the Texas State Board of Medical Examiners.
  8. A current copy of a certificate for Texas Controlled substances registration issued by the Texas Dept. of Public Safety.
  9. A current copy of a certificate for controlled substance registration issued by the U.S. Dept. of Justice Drug Enforcement Administration, Washington, D.C. Administration, Washington, D.C. (DEA certificate)
  10. Texas Credentialing Form (On Intranet with other contractor documents)
  11. Other Professionals
  12. Licenses as required
  13. Other Certifications as required
  14. Criminal History Check Form
  15. DPS Computerized Criminal History Form
  16. Confidentiality Form
  17. Attestation Form
  18. Business Code of Conduct Signature Page
  19. Copy ofDeclaration of Liability Insurance (Requirements on Intranet with Contract Forms)
  20. General Liability (Premises/Operations -if they perform services on our grounds)
  21. Professional Liability (Directly works with our clients)
  22. Automobile Liability (Uses own vehicle in performing duties; Note: cannot drive a CHC vehicle)

Contractor’s Information (Contract Manager fills this out and sends to Peggy Bagley, Unit #177, with other contract forms)

Business Name

Contract Person

Mailing Address ______

Telephone # ______Cell/Fax/Other Phone # ______

Center’s Information

Detailed Job/Services, Locations, and Frequency of Services (bullet the specific tasks that the Consultant will be performing).

Rate of Pay for Services______

Payment for Training:

Unit Number(s) Charged To ______

Total amount of money actually budgeted in Forecaster

and should not be exceeded for the fiscal year without

a written amendment:

Start Date and End Date ______

(All contracts must have end dates. If not indicated, the final date will be the end of the fiscal year)

Program Manager/Supervisor

(Person signing invoices and monitoring contractor’s services)