TX HHS Form 3681. Community Services Contract Application

Form 3681 is used in Texas to apply for or update a Community Services Contract with the Health and Human Services Commission (HHSC). New and current providers use this form to submit legal entity information, request new contract types, and verify compliance with state and federal requirements.

Purpose of Form 3681

This form is required for organizations and individuals who provide community-based services and need to:

• Apply as a new HHSC-approved provider
• Update business, ownership, or licensing information
• Request additional HHSC contract types
• Verify compliance with state and federal program standards

Main Sections of the Form

Applicant Information

Indicates whether the applicant is a new or current provider and the reason for submitting the form.

Legal Entity Information

Includes business name, DBA, tax ID, NPI/API numbers, mailing and physical addresses, authorized representative, and record-keeping location.

Type of Legal Entity

Specifies whether the applicant is a sole proprietorship, corporation, LLC, partnership, nonprofit, or governmental entity. Certain entity types must attach supporting documents.

Adverse Actions and Convictions

Requires disclosure of criminal convictions, pending charges, sanctions, compliance agreements, outstanding debts, and past license denials or revocations. Supporting explanations must be attached if applicable.

Ownership Information

Reports recent ownership changes, relationships between owners, ownership transfers related to penalties, planned ownership changes, and anticipated bankruptcy filings.

Internal Review Requirement

Confirms the applicant has verified that no owners, employees, or contractors are excluded from federal or state program participation.

Requested Contract Types

Applicants list the abbreviations of HHSC contract types they wish to obtain, based on the official contract type list.

HCS and TxHmL Program Information

For Home and Community-based Services and Texas Home Living providers, the form requires details for the program contact, billing contact, and program manager. The program manager must attend HHSC training and provide a resume and three references.

Licensure Information

For applicants requiring an HHS license, this section includes license numbers, facility categories, HCSSA service categories, and branch office locations. Certain facilities must also provide proof of legal right to occupy the property.

Certification

The owner or authorized representative must certify that all information is accurate and complete. Incorrect information may result in denial or cancellation of the contract.

Who Uses Form 3681

• Home and Community-based Services (HCS) providers
• Texas Home Living (TxHmL) providers
• Assisted Living Facilities
• Home Health and Hospice agencies
• Day Activity and Health Services providers
• Nonprofit and for-profit community service organizations
• Governmental service providers contracting with HHSC

Required Attachments

Depending on the applicant’s circumstances, the following documents may be required:

• Entity formation certificates and legal documents
• Explanations and records for any convictions or sanctions
• Ownership transfer records
• Program manager resume and references (for HCS/TxHmL)
• Licensing records and facility documentation
• Proof of right to occupy facility property

Key Form Details

• Form Number: 3681
• Title: Community Services Contract Application
• Issued by: Texas Health and Human Services Commission
• State: Texas
• Revision Date: June 2024