Electronic Document Submission (EDS)

Electronic Document Submission (EDS) Pilot Participation Request Form

Provider Name Contract #

Contact Name Title

Email Phone

Back-up Email

Please check the appropriate boxes for the programs that your agency offers under each DADS Regional Office. The counties covered by these offices are listed in the attached letter. This form will be used to create a master list of provider agencies that will be participating in the pilot. Offices and Programs

Houston-(1332 E 40 th) Adult Foster Care Emergency Response Assisted Living/Residential Care Family Care Provider Community Attendant Services Home Delivered Meals Community Based Alternatives Medically Dependent Children Program Consumer Directed Service Agency Primary Home Care Day Activity and Health Service Transition Assistance Services

Midland - (901 W. Wall) Adult Foster Care Emergency Response Assisted Living/Residential Care Family Care Provider Community Attendant Services Home Delivered Meals Community Based Alternatives Medically Dependent Children Program Consumer Directed Service Agency Primary Home Care Day Activity and Health Service Transition Assistance Services

Odessa - (9016 Kermit Hwy.) Adult Foster Care Emergency Response Assisted Living/Residential Care Family Care Provider Community Attendant Services Home Delivered Meals Community Based Alternatives Medically Dependent Children Program Consumer Directed Service Agency Primary Home Care Day Activity and Health Service Transition Assistance Services Pecos - (324 South Cypress St) Adult Foster Care Emergency Response Assisted Living/Residential Care Family Care Provider Community Attendant Services Home Delivered Meals Community Based Alternatives Medically Dependent Children Program Consumer Directed Service Agency Primary Home Care Day Activity and Health Service Transition Assistance Services

Waco-(801 Austin Ave.) Adult Foster Care Emergency Response Assisted Living/Residential Care Family Care Provider Community Attendant Services Home Delivered Meals Community Based Alternatives Medically Dependent Children Program Consumer Directed Service Agency Primary Home Care Day Activity and Health Service Transition Assistance Services

Once this form is filled out completely, please email this form to [email protected].