Get Form 3691-a Service Area Designation Hcs Txhml Cds And Tas Form 3619-a - Dads State Tx

This guide provides a clear and comprehensive approach to completing the Form 3691-A, which is essential for designating service areas for various contract types within the Texas Department of Aging and Disability Services (DADS). Follow the steps outlined to ensure accurate and efficient submission of your application.

Follow the steps to successfully fill out your Form 3691-A online.

1. Click ‘Get Form’ button to obtain the form and open it in your editor for filling out.
2. In Section 1, fill out the legal entity information. Provide the legal entity name, type of contract, National Provider Identifier (NPI), contact person's name, area code and telephone number, and taxpayer identification number.
3. Proceed to Section 2 based on your contract type from Section 1. If your contract type is CDS-CLASS, skip to Section 3. If it is HCS, TxHmL, CDS-HCS, or CDS-TxHmL, check the applicable boxes to indicate the regions and counties where you wish to offer services.
4. If completing Section 3 (for CDS-CLASS), check the relevant boxes indicating which catchment areas you wish to serve. Ensure you are servicing all counties in each selected catchment area.
5. In Section 4, check the boxes corresponding to the waiver contract areas you intend to serve if your contract type requires it. Note that you must serve all counties covered by each local service area selected.
6. Finally, complete Section 5 by certifying the information provided on the form is true and complete. Sign and date the form, and include the title of the authorized representative.
7. After filling out all sections, you can save your changes, download the form for your records, print it, or share it with the relevant parties online.

Complete your documents online today to streamline your application process.