TX HHS Form 3691. Service Area Designation

The TX HHS Form 3691, Service Area Designation, is a crucial document for organizations seeking to provide various services in the Health and Human Services Commission (HHSC) region or catchment area. This form helps solve the problem of designating service areas for Adult Foster Care, Residential Care, Texas Home Living, Home and Community-based Services, Consumer Directed Services, and Transition Assistance Services.

This form requires specific information, including legal entity details, such as name, region number, national provider identifier (NPI), catchment area name, contact person name, area code, and telephone number. Additionally, applicants must provide service locations and areas for each type of contract, including physical addresses, county names, and license numbers if applicable.

The form is designed to be used by organizations that want to contract with HHSC to provide services in a specific region or catchment area. It's essential to note that Home and Community Support Services agencies must be licensed to provide services in the counties listed in Section 2. The form should be completed for each region or catchment area where services will be provided, and additional copies of this page may be needed if multiple regions are involved.