Psychiatric Services Procurement Number: HHS0000018Attachment A-3a-Service Delivery Area Detail Page 1

Legal Entity Name:______________________________________

Service Delivery Area

Select the counties within the Region where services will be provided. Check (“√”) the box in front of the county name to select the counties to be served. Select a single county or any combination of counties.

Counties To Be Served – Region 1☐ Armstrong ☐ Garza ☐ Moore☐ Bailey ☐ Gray ☐ Motley☐ Briscoe ☐ Hale ☐ Ochiltree☐ Carson ☐ Hall ☐ Oldham☐ Castro ☐ Hansford ☐ Parmer☐ Childress ☐ Hartley ☐ Potter☐ Cochran ☐ Hemphill ☐ Randall☐ Collingsworth ☐ Hockley ☐ Roberts☐ Crosby ☐ Hutchinson ☐ Sherman☐ Dallam ☐ King ☐ Swisher☐ Deaf Smith ☐ Lamb ☐ Terry☐ Dickens ☐ Lipscomb ☐ Wheeler☐ Donley ☐ Lubbock ☐ Yoakum☐ Floyd ☐ Lynn

Psychiatric Services Procurement Number: HHS0000018Attachment A-3a-Service Delivery Area Detail Page 2

Legal Entity Name:______________________________________

Service Delivery AreaCounties To Be Served – Region 2

Select the counties within the Region where services will be provided. Check (“√”) the box in front of the county name to select the counties to be served. Select a single county or any combination of counties.

Regional Counties Available for Enrollment

Note: All counties within a Region may not be currently available for enrollment.Only counties in bold and with a “☐” in front of the county name are available for enrollment.

☐ Archer ☐ Foard ☐ Runnels☐ Baylor ☐ Hardeman ☐ Scurry☐ Brown ☐ Haskell ☐ Shackelford☐ Callahan ☐ Jack ☐ Stephens☐ Clay ☐ Jones ☐ Stonewall☐ Coleman ☐ Kent ☐ Taylor☐ Comanche ☐ Knox ☐ Throckmorton☐ Cottle ☐ Mitchell ☐ Wichita☐ Eastland ☐ Montague ☐ Wilbarger☐ Fisher ☐ Nolan ☐ Young

Psychiatric Services Procurement Number: HHS0000018Attachment A-3a-Service Delivery Area Detail Page 3

Legal Entity Name:______________________________________

Service Delivery AreaCounties To Be Served – Region 3

Select the counties within the Region where visitation services will be provided. Check (“√”) the box in front of the county name to select the counties to be served. Select a single county or any combination of counties.

☐ Collin ☐ Grayson ☐ Palo Pinto☐ Cooke ☐ Hood ☐ Parker☐ Dallas ☐ Hunt ☐ Rockwall☐ Denton ☐ Johnson ☐ Somervell☐ Ellis ☐ Kaufman ☐ Tarrant☐ Erath ☐ Kent ☐ Wise☐ Fannin ☐ Navarro

Service Delivery AreaCounties To Be Served – Region 4

Select the counties within the Region where services will be provided. Check (“√”) the box in front of

Psychiatric Services Procurement Number: HHS0000018Attachment A-3a-Service Delivery Area Detail Page 4

Legal Entity Name:______________________________________

the county name to select the counties to be served. Select a single county or any combination of counties.☐ Anderson ☐ Harrison ☐ Red River☐ Bowie ☐ Henderson ☐ Rusk☐ Camp ☐ Hopkins ☐ Smith☐ Cass ☐ Lamar ☐ Titus☐ Cherokee ☐ Marion ☐ Upshur☐ Delta ☐ Morris ☐ Van Zandt☐ Franklin ☐ Panola ☐ Wood☐ Gregg ☐ Rains

Psychiatric Services Procurement Number: HHS0000018Attachment A-3a-Service Delivery Area Detail Page 5

Legal Entity Name:______________________________________

Service Delivery AreaCounties To Be Served – Region 5

Select the counties within the Region where services will be provided. Check (“√”) the box in front of the county name to select the counties to be served. Select a single county or any combination of counties.

☐ Angelina ☐ Nacogdoches ☐ San Augustine☐ Hardin ☐ Newton ☐ San Jacinto☐ Houston ☐ Orange ☐ Shelby☐ Jasper ☐ Polk ☐ Trinity☐ Jefferson ☐ Sabine ☐ Tyler

Psychiatric Services Procurement Number: HHS0000018Attachment A-3a-Service Delivery Area Detail Page 6

Legal Entity Name:______________________________________

Service Delivery AreaCounties To Be Served – Region 6

Select the counties within the Region where services will be provided. Check (“√”) the box in front of the county name to select the counties to be served. Select a single county or any combination of counties.☐ Austin ☐ Galveston ☐ Montgomery☐ Brazoria ☐ Harris ☐ Walker☐ Chambers ☐ Liberty ☐ Waller☐ Colorado ☐ Matagorda ☐ Wharton☐ Fort Bend

Psychiatric Services Procurement Number: HHS0000018Attachment A-3a-Service Delivery Area Detail Page 7

Legal Entity Name:______________________________________

Service Delivery AreaCounties To Be Served – Region 7

Select the counties within the Region where services will be provided. Check (“√”) the box in front of the county name to select the counties to be served. Select a single county or any combination of counties.☐ Bastrop ☐ Fayette ☐ Llano☐ Bell ☐ Freestone ☐ Madison☐ Blanco ☐ Grimes ☐ McLennan☐ Bosque ☐ Hamilton ☐ Milam☐ Brazos ☐ Hays ☐ Mills☐ Burleson ☐ Hill ☐ Robertson☐ Burnet ☐ Lampasas ☐ San Saba☐ Caldwell ☐ Lee ☐ Travis☐ Coryell ☐ Leon ☐ Washington☐ Falls ☐ Limestone ☐ Williamson

Psychiatric Services Procurement Number: HHS0000018Attachment A-3a-Service Delivery Area Detail Page 8

Legal Entity Name:______________________________________

Service Delivery AreaCounties To Be Served – Region 8

Select the counties within the Region where services will be provided. Check (“√”) the box in front of the county name to select the counties to be served. Select a single county or any combination of counties.☐ Atascosa ☐ Goliad ☐ Lavaca☐ Bandera ☐ Gonzales ☐ Maverick☐ Bexar ☐ Guadalupe ☐ Medina☐ Calhoun ☐ Jackson ☐ Real☐ Comal ☐ Karnes ☐ Uvalde☐ De Witt ☐ Kendall ☐ Val Verde☐ Dimmit ☐ Kerr ☐ Victoria☐ Edwards ☐ Kinney ☐ Wilson☐ Frio ☐ La Salle ☐ Zavala☐ Gillespie

Psychiatric Services Procurement Number: HHS0000018Attachment A-3a-Service Delivery Area Detail Page 9

Legal Entity Name:______________________________________

Service Delivery AreaCounties To Be Served – Region 9

Select the counties within the Region where services will be provided. Check (“√”) the box in front of the county name to select the counties to be served. Select a single county or any combination of counties.☐ Andrews ☐ Howard ☐ Reagan☐ Borden ☐ Irion ☐ Reeves☐ Coke ☐ Kimble ☐ Schleicher☐ Concho ☐ Loving ☐ Sterling☐ Crane ☐ Martin ☐ Sutton☐ Crockett ☐ Mason ☐ Terrell☐ Dawson ☐ McCulloch ☐ Tom Green☐ Ector ☐ Menard ☐ Upton☐ Gaines ☐ Midland ☐ Ward☐ Glasscock Pecos Winkler

Psychiatric Services Procurement Number: HHS0000018Attachment A-3a-Service Delivery Area Detail Page 10

Legal Entity Name:______________________________________

Service Delivery AreaCounties To Be Served – Region 10

Select the counties within the Region where services will be provided. Check (“√”) the box in front of the county name to select the counties to be served. Select a single county or any combination of counties.☐ Brewster ☐ El Paso ☐ Jeff Davis☐ Culberson ☐ Hudspeth ☐ Presidio

Psychiatric Services Procurement Number: HHS0000018Attachment A-3a-Service Delivery Area Detail Page 11

Legal Entity Name:______________________________________

Service Delivery AreaCounties To Be Served – Region 11

Select the counties within the Region where services will be provided. Check (“√”) the box in front of the county name to select the counties to be served. Select a single county or any combination of counties.☐ Aransas ☐ Jim Wells ☐ Refugio☐ Bee ☐ Kenedy ☐ San Patricio☐ Brooks ☐ Kleberg ☐ Starr☐ Cameron ☐ Live Oak ☐ Webb☐ Duval ☐ McMullen ☐ Willacy☐ Hidalgo ☐ Nueces ☐ Zapata☐ Jim Hogg