Instructions for completing the Disclosures Page
Instructions for updating the Disclosures Page
Select the Application Type from the left navigation menu.
You must answer “Yes” or “No” as it pertains to the enrolling National Provider Identifier (NPI) for each of the questions included in the "Disclosures" page of the TMHP Provider Enrollment and Management System (PEMS). Your answers should address all past and current actions as applicable.
You must answer “Yes” or “No” as it pertains to the reenrolling National Provider Identifier (NPI) for each of the questions included in the "Disclosures" page of the TMHP Provider Enrollment and Management System (PEMS). Your answers should address all past and current actions as applicable.
You must answer “Yes” or “No” as it pertains to the revalidating National Provider Identifier (NPI) for each of the questions included in the "Disclosures" page of the TMHP Provider Enrollment and Management System (PEMS). Your answers should address all past and current actions as applicable.
You must answer “Yes” or “No” as it pertains to the current National Provider Identifier (NPI) for each of the questions included in the "Disclosures" page of the TMHP Provider Enrollment and Management System (PEMS). Your answers should address all past and current actions as applicable.
You must answer “Yes” or “No” as it pertains to the existing National Provider Identifier (NPI) for each of the questions included in the "Disclosures" page of the TMHP Provider Enrollment and Management System (PEMS). Your answers should address all past and current actions as applicable.
“Sanction” is defined as recoupment, payment hold, imposition of penalties or damages, contract cancellations, exclusion, debarment, suspension, revocation, or any other synonymous action.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each action: .
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each action:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each action:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each action:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each outstanding debt or unpaid amount due:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each cause of arrest:
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s) ( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each charge or conviction:
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s)( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each charge or conviction:
Date (Approximate Date Allowed)—Enter the date.
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s)( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each charge or conviction:
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s)( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each arrest or outstanding warrant:
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s)( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
Make a selection from the drop-down menu in order to associate each attachment to a question. If you have attachments that you have added to this page, select the drop-down menu to associate each attachment to the corresponding question.
Click Save.
When you have completed your updates, click Submit All Changes.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each action: .
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each action:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each action:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each outstanding debt or unpaid amount due:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each cause of arrest:
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s) ( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each charge or conviction:
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s)( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each charge or conviction:
Date (Approximate Date Allowed)—Enter the date.
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s)( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each charge or conviction:
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s)( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each arrest or outstanding warrant:
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s)( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Attach all relevant documentation for the proof of compliance to repayment, along with a payment plan, to this page. If unable to provide documentation, explain why and where it can be obtained.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Note: If you select "No" to the United States citizen question, the following will be enabled:
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
If you selected "No," indicate of which country are you a citizen.
Note: If you selected "No," indicate of which country are you a citizen. to this: If you selected "No," indicate your country of citizenship.
Do you have the legal right to work within the United States? Click Yes or No.
If you answered "Yes," submit a copy of your Permanent Resident Card, visa or other documentation demonstrating your right to reside and work in the United States.
A list of acceptable documentation is provided on the U.S. Citizenship & Immigration Services website at: www.uscis.gov/i-9-central/form-i-9-acceptable-documents.
Add documentation of visa/documentation to the page.
Make a selection from the drop-down menu in order to associate each attachment to a question. If you have attachments that you have added to this page, select the drop-down menu to associate each attachment to the corresponding question.
Click Save.
When you have completed your updates, click Submit All Changes.
Instructions for completing the Disclosures Page
You must answer “Yes” or “No” as it pertains to the enrolling National Provider Identifier (NPI) for each of the questions included in the "Disclosures" page of the TMHP Provider Enrollment and Management System (PEMS). Your answers should address all past and current actions as applicable.
“Sanction” is defined as recoupment, payment hold, imposition of penalties or damages, contract cancellations, exclusion, debarment, suspension, revocation, or any other synonymous action.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each action: .
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each action:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each action:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each outstanding debt or unpaid amount due:
Date (Approximate Date Allowed) - Enter the Date
State Where the Incident Occurred – Select the State from the available drop-down menu
Program Affected – Enter the Program Affected
Agency Taking the Action – Enter the Agency taking action against you
Action Taken – Enter the Action Taken
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each cause of arrest:
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s) ( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each charge or conviction:
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s)( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each charge or conviction:
Date (Approximate Date Allowed)—Enter the date.
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s)( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each charge or conviction:
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s)( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each arrest or outstanding warrant:
Date (Approximate Date Allowed)—Enter the date.
State Where the Incident Occurred—Select the state from the available drop-down menu.
County—Select the county from the drop-down menu.
Court- Select the Court from the available drop-down menu
Case/Cause Number(s) - Enter the Case/Cause number(s)( Optional )
Charge - Enter the Charge
Explanation/Details - Provide a detailed explanation of the charges against you
If disclosure is for a prior Exclusion, provide Reinstatement documentation from HHSC/OIG and attach to this page
If you have more than one response, you can select Add Response to save the current response and bring up a new template for your next response.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Attach all relevant documentation for the proof of compliance to repayment, along with a payment plan, to this page. If unable to provide documentation, explain why and where it can be obtained.
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
Note: If you select "No" to the United States citizen question, the following will be enabled:
If you selected "Yes”, you must explain the details in the additional fields provided below the question. Your explanation must include all of the following details for each program:
If you selected "No," indicate of which country are you a citizen.
Note: If you selected "No," indicate of which country are you a citizen. to this: If you selected "No," indicate your country of citizenship.
Do you have the legal right to work within the United States? Click Yes or No.
If you answered "Yes," submit a copy of your Permanent Resident Card, visa or other documentation demonstrating your right to reside and work in the United States.
A list of acceptable documentation is provided on the U.S. Citizenship & Immigration Services website at: www.uscis.gov/i-9-central/form-i-9-acceptable-documents.
Add documentation of visa/documentation to the page.
Make a selection from the drop-down menu in order to associate each attachment to a question. If you have attachments that you have added to this page, select the drop-down menu to associate each attachment to the corresponding question.
Click Save.
When you have completed your updates, click Submit All Changes.