TX HHS Form 3243. Affiliate Sex Offender Treatment Provider or Licensed Sex Offender Treatment Provider Name Change or Duplicate License Application

Form 3243 is an official application used by licensed professionals in the field of sex offender treatment in Texas to request a name change on their license or to obtain duplicate copies of their license and renewal cards. It ensures that licensees can update their personal information or replace lost documents while maintaining compliance with state regulations.

Purpose and Usage of the Form

This form serves as a formal request mechanism for individuals holding specific licenses related to sex offender treatment. It is primarily used to apply for a name change on the license due to legal reasons such as marriage, divorce, or other personal updates, or to request duplicates if the original license or renewal cards are lost, damaged, or stolen. The form helps maintain accurate records with the licensing authority, ensuring that professional credentials reflect current and correct information. Without this update, discrepancies in names could lead to issues in professional practice, verification, or renewal processes.

Who Uses This Form

The form is intended for two types of licensees regulated by the Council on Sex Offender Treatment in Texas:

• Affiliate Sex Offender Treatment Providers (ASOTP), who are entry-level or supervised professionals in the field.
• Licensed Sex Offender Treatment Providers (LSOTP), who are fully qualified and independent practitioners.

These professionals work in therapeutic settings, providing counseling and treatment to individuals convicted of sex offenses, often as part of court-mandated programs. Only current licensees with an active or expiring license from this council are eligible to submit this form.

When and Why the Form is Needed

Form 3243 is required in situations where a licensee's name has legally changed, such as through marriage, adoption, or court order, and they need their professional credentials updated to match. It is also used when duplicates are necessary due to loss, theft, or destruction of the original license documents. This ensures continuity in professional activities, as accurate licensing is essential for employment, insurance billing, legal compliance, and public safety in sensitive fields like offender treatment. Submitting this form prevents potential disruptions in practice and upholds the integrity of the licensing system.

Structure and Sections of the Form

The form is divided into clear sections to collect necessary information efficiently. It begins with identifying the licensure type and then proceeds to profile data, specific requests, fees, and signature.

Licensure Type

Applicants must indicate their license category by checking one of the following:

• Affiliate Sex Offender Treatment Provider (ASOTP)
• Licensed Sex Offender Treatment Provider (LSOTP)

This ensures the request is processed under the correct regulatory framework.

Section 1: Licensee Profile Data

This section gathers essential personal and contact information to verify the applicant's identity and update records. It requests:

• License Number: The unique identifier assigned to the license.
• Expiration Date: The date when the current license expires.
• Name or New Name: The current or updated full name of the licensee.
• Area Code and Phone Number: Contact telephone details for communication.
• Former Name, if Applicable: The previous name, relevant for name change requests.
• Street Address, City, State, and ZIP Code: The licensee's mailing address for sending updated documents.
• Email Address: For electronic notifications and confirmations.

Accurate completion of this section is crucial for matching the request to existing records and avoiding processing delays.

Section 2: Duplicate License Request

Here, applicants specify the type of request:

• Request for Name Change Duplicate License and Renewal Cards: This option requires attaching supporting documentation, such as a photocopy of a new Social Security card, driver's license, or marriage certificate, to verify the name change. Note that if the individual holds multiple licenses from different programs or boards, they must notify each one separately.
• Request for Duplicate License and Renewal Cards Only: For cases where no name change is involved, just replacements are needed.

This section ensures that the council has evidence for changes and processes only valid requests.

Section 3: Duplicate License Fee

A mandatory $10 fee is required, as stipulated by Texas Administrative Code Title 22 §810.5(i). This fee must be included with the application package. Payment covers administrative costs for processing and issuing duplicates.

Section 4: Signature

The licensee must provide their signature and the date of signing to certify the accuracy of the information and authorize the request. This acts as a legal acknowledgment and is essential for the form's validity.

Submission Requirements and Process

To submit, applicants must mail the completed form, any required supporting documents, and the $10 fee to the specified address: HHS ARTS, Mail Code 1470, P.O. Box 149055, Austin, Texas 78714-9055. For inquiries or assistance, email [email protected]. There are no online submission options mentioned, emphasizing the need for physical mailing to ensure secure handling of sensitive personal information.

Key requirements include:

• Providing complete and accurate data to prevent rejection.
• Attaching verifiable proof for name changes.
• Including the exact fee amount.
• Ensuring the form is signed and dated.

Failure to meet these could result in delays or denial of the request. Licensees should retain copies of all submitted materials for their records.

Key Form Details

Form Name: Affiliate Sex Offender Treatment Provider or Licensed Sex Offender Treatment Provider Name Change or Duplicate License Application

Form Number: 3243

Issuing Organization: Council on Sex Offender Treatment, under Texas Health and Human Services (HHS)

Edition Date: April 2022-E