Attach all documents and pertinent information that might be needed for HHSC to complete the review of your investigation.
Fax: Fax this report to (if 15 total pages or fewer): 877-438-5827.
Email: Email this report to: ciiprovider@hhs.texas.gov.
Criminal history: do not send printed copies of actual criminal history reports obtained from the Department of Public Safety (DPS) secure site.
Complete: HHSC does not accept this report as complete until the reporter's signature, printed name, title and date have been entered.
| Question | Answer |
|---|---|
| Form Name | Form 3613 |
| Form Length | 4 pages |
| Fillable? | Yes |
| Fillable fields | 190 |
| Avg. time to fill out | 32 min |
| Edition | October 2023 |
| Where to 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 |
| Matches the agency's file | Yes, checked October 4, 2026 |
| Other names | Form 3613, 3613, 3613 form, 3613-A, Provider Investigation Report, HCSSA Provider Investigation Report |
| Official source | Form 3613 (Rev October 2023), Texas Health and Human Services Commission |
Form 3613 isn’t the one you’re looking for?