Effective Date: 
3/2018

Documents

 

Instructions

Updated: 5/2017

 

Purpose

Form 3691-A is completed by individuals and organizations applying to contract with the Health and Human Services Commission (HHSC) to provide Home and Community-based Services (HCS), Texas Home Living (TxHmL), Consumer Directed Services (CDS) and Transition Assistance Services (TAS) to specify the HHSC service area(s) they wish to serve.

 

Instructions for HHSC Staff

When to Prepare

Obtain a completed and signed Form 3691-A for:

  • a new contract, and
  • a contract amendment that changes the designated service area.

Form Retention

Retain Form 3691-A in accordance with the records retention requirements in the Health and Human Services System Contract Management Handbook.

 

Applicant's Instructions for Completing Form 3691-A

Carefully read the following instructions. Errors and omissions will cause delays in processing Form 3691-A.

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.

Type of Contract — Use the list of contract types included on page 3 of these instructions to indicate the type of contract you wish to obtain. Enter the abbreviation listed in the first column for the contract type. Only one contract type may be entered. If you wish to obtain more than one contract type, you must complete a separate Form 3691-A for each contract type.

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 Form 3691-A.

Taxpayer Identification No. — Enter the nine-digit employer identification number (EIN) assigned the legal entity by the Internal Revenue Service. If an individual or sole proprietorship does not have to obtain an EIN, enter the individual's Social Security number.

Section 2. Service Areas by Region

Check the applicable boxes to indicate the regions and counties you wish to provide services for the contract type specified in Section 1.

Section 3. Service Areas by Catchment Area (CDS-CLASS)

Check the applicable boxes to indicate the catchment areas you wish to provide CDS-CLASS. You must serve all counties in each catchment area selected. Click here to view list of counties by catchment area.

Section 4. Service Areas by Waiver Contract Area (HCS, TxHmL, CDS-HCS and CDS-TxHmL)

Check the applicable boxes to indicate the service areas you wish to serve. You must serve all counties served by each local service area selected. Click here to view list of counties by local service area.

Section 5. Legal Entity Certification

The owner or authorized representative of the legal entity identified in Section 1 must certify the information provided on the form 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.

List of Contract Types for Form 3691-A

Abbreviation Contract Type
HCS Home and Community-based Services
TxHmL Texas Home Living
CDS-CLASS Consumer Directed Services — Community Living Assistance and Support Services
CDS-CMPAS Consumer Directed Services — Client Managed Personal Attendant Services
CDS-DBMD Consumer Directed Services — Deaf Blind with Multiple Disabilities
CDS-PHC Consumer Directed Services — Primary Home Care
CDS-HCS Consumer Directed Services — Home and Community-based Services
CDS-TxHmL Consumer Directed Services — Texas Home Living
TAS Transition Assistance Services — Contractor serves individuals in the following program areas:
Deaf Blind with Multiple Disabilities
Community Living Assistance Support Services

 

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