THE GULFCOASTCENTER
IDD Provider of Services
7000 Ave. B
Santa Fe, Texas77510
IDD CONTRACT AGENCYSERVICE PACKET
COVER SHEET
Dear Potential Agency Provider,
Please place INITIALS in BOXES below of all ITEMS being returned.
GCC FORMS TO BE COMPLETED (signed/dated) AND RETURNED:
IDD Contract Agency Service Packet Cover sheet (rev 2-2014)- this form (2 pgs. return)
FY 2014 GCC-IDD-Open-Enrollment-Application JAN 2014 (complete attachment B1)
FY 2014 Provider Agency Contract
Authorization for Contract Provider Background Check (rev 1-14)
DPS Audit Verification
REQUIRED DOCUMENTS TO BE SUBMITTEDANNUALLY OR AS THEY ARE RENEWED OR UPDATED:
Historically underutilized Business Vendor form(Annually)
Certificate of Liability - General Liability Insurance naming GCC as an additional insured
Certificate of Liability – vehicle insurance
Annual safety inspection –completed by GCC safety officer
Annual Fire Marshall Inspection (annually)
Quarterly Fire Drills
Fire Alarm Inspection (annually)
Agency Emergency Procedures
Agency Admission/Discharge Procedures
HIV/Aids Workplace Guidelines
Copy of Valid Driver’s License of each employee
Copy of High School Diploma, GED (required only at time contract is initiated)
Three Letters of Reference (if no High School Diploma /GED)(required only at time contract is initiated)
Agency Email/Home/Cell Phone numbers (updated regularly)
TRAININGS REQUIRED ON ALL AGENCY EMPLOYEES WORKING WITH GCC CONSUMERS (Additional Trainings may be required that are specific to the person to whom youare providing services; ie: High Blood Pressure, Diabetes, Tube Feeding, Transferring(Wheel Chair), etc.
Rights Acknowledgment Form (must review 2013 Corporate Compliance & Rights Protection Training)
2013 Corporate Compliance & Rights Protection Training
Acknowledgment of Receipt & Understanding of HIPAA Privacy Training (must review Privacy
Training Module HIPAA)
Privacy Training Module HIPAA
Infection Control Study Manual and Test
Screening and Crisis Manual and Test
Diabetes Study Guide and Training, High Blood Pressure Study Guide and
Test,Hypothyroidism Study Guide and Acknowledgement form(as per consumer needs)
Copy of CPR and 1st Aid
Preventing Managing Aggressive Behavior (PMAB) (as needed & determined by staff/family members)
Supervision of the Self Administration of Medication training (only if administering meds to
GCC consumers)(GCC on-line trainings -12.00/yr).
Normalization and Sensitivity
Intro to IDD
(Please Print)
Name of Agency ______
Agency contact person______
(rev 2-2014)
Our mission is to enable and empower individuals and families to live quality lives
IDD CONTRACT SERVICES PACKET COVER SHEET - PROVIDERS