Please rate Form 3613 A April 2024
Attach all documents and pertinent information for HHSC to complete the review of your investigation.
Contact: your HHSC Regional Office may also contact you to request more information to complete the review.
Alleged perpetrator: if the alleged perpetrator is somebody other than a staff member, indicate this person's relationship to the person.
Witness: did the investigation reveal the presence of a witness? Statement, signed and notarized if possible?
Other parties: were other parties notified? Example: physician, family, ombudsman.
| Question | Answer |
|---|---|
| Form Name | Form 3613-A |
| Form Length | 4 pages |
| Fillable? | Yes |
| Fillable fields | 117 |
| Avg. time to fill out | 20 min |
| Edition | April 2024 |
| Where to send | By fax: 877-438-5827 toll free; by email: ciiprovider@hhs.texas.gov; by mail: Texas Health and Human Services Commission, Regulatory Services, Complaint and Incident Intake, Mail Code E-249, P.O. Box 149030, Austin, TX 78714-9030 |
| Other names | 3613-A, 3613A, Form 3613-A, Form 3613A, Form 3613, Provider Investigation Report |
| Official source | Form 3613-A (April 2024), Texas Health and Human Services Commission |
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Please rate Form 3613 A April 2024
