Form 3691 is completed by individuals and organizations applying to contract with the Health and Human Services Commission (HHSC) to specify the HHSC service area(s) they wish to serve.
Note: Applicants who want to contract to provide Adult Foster Care or Residential Care do not have to complete this form. Applicants who want to contract to provide Home and Community-based Services, Texas Home Living, Consumer Directed Services and Transition Assistance Services must complete Form 3691-A, Service Area Designation — HCS, TxHmL, CDS and TAS, instead of this form.
Instructions for HHSC Staff
When to Prepare
Obtain a completed and signed Form 3691 for:
- a new contract, and
- an update of information.
Retain Form 3691 and attachments, if any, in accordance with the records retention requirements in the Health and Human Services System Contract Management Handbook.
Applicant's Instructions for Completing Form 3691
Carefully read the instructions. Errors and omissions will cause delays in processing Form 3691.
Section 1. Legal Entity Information
Legal Entity Name — Enter the full, legal name of the entity, exactly as it was chartered, filed, registered or otherwise legally declared.
National Provider Identifier (NPI) — Enter the ten-digit NPI number issued to the legal entity by the National Plan and Provider Enumeration System, if applicable.
Contact Person Name — Enter the name and telephone number of the person who can answer questions about the information furnished on the form.
Taxpayer Identification No. — Enter the nine-digit employer identification number (EIN) assigned the legal entity by the Internal Revenue Service. If the legal entity is a sole proprietorship or individual who does not have an EIN, enter the owner's or individual's Social Security number (SSN).
Section 2. Service Locations and Areas
Complete a separate part of Section 2 for each type of contract you wish to obtain.
Click on Community Services Contract Types for a list of contract types. Enter the contract type abbreviation listed in the first column to indicate the type of contract you wish to obtain. Enter only one contract type; do not combine contract types in one part.
License No. — If the services you wish to provide require a license, enter the license number of the legal entity or the facility, whichever is applicable.
Name of Location — Enter the legal entity's name or d/b/a (doing business as), whichever is applicable.
Physical Address — Self-explanatory.
County Name — List the counties in the region or catchment area indicated in Section 1 that you wish to serve. If you checked the region box in Section 1 and you wish to serve all counties in the region indicated, check the All Counties box in lieu of listing the counties. The counties selected for programs that require a license must match the counties identified on the license. Applicants who want to provide CLASS must serve all counties in a catchment area.
Complete a separate Form 3691 for each region or catchment area you want to serve. Attach additional copies of Page 1, as needed. Click on the links below to view lists of counties by service region and catchment area.
List of Counties by Catchment Area (CLASS only)
Section 3. Legal Entity Certification
The owner or authorized representative of the legal entity identified in Section 1 must certify the information provided on the form, as well as all attachments, is true and correct. If an authorized representative provides this certification, that person must be named on a current Form 2031, Governing Authority Resolution – Business Organization, or Form 2031-G, Governing Authority Resolution – Governmental Entity, whichever is applicable to the legal entity.