TX HHS Form 3691. Service Area Designation

The TX HHS Form 3691, Service Area Designation, helps solve the problem of designating a specific service area for health and human services providers. This form is typically used by organizations that want to contract with the Texas Health and Human Services (HHS) Commission to provide various types of services, such as Adult Foster Care or Residential Care.

The form requires applicants to provide legal entity information, including name, region number, national provider identifier, catchment area name, contact person name, area code and telephone number, and taxpayer identification number. Additionally, applicants must complete the service locations and areas section, which includes providing information about each type of contract and location that will provide services in a specific HHSC region or catchment area.

If you wish to provide services in more than one region or catchment area, you must complete a separate Form 3691 for each region or catchment area. Key points to note include:

• Applicants who want to contract to provide Texas Home Living, Home and Community-based Services, Consumer Directed Services and Transition Assistance Services must complete Form 3691-A instead of this form.
• Home and Community Support Services agencies must be licensed to provide services in the counties listed in Section 2.