Texas Form 5913 PDF Details

Are you looking for information about Texas Form 5913? You’ve come to the right place! This blog post will walk you through everything you need to know about filing this form, from legal requirements and exemptions to how to properly complete it. We’ll even provide helpful tips on what documents may be required and give examples of frequently asked questions. Whether you’re a business owner in Texas, or just someone wanting to learn more about what this form means and how it could affect your taxes, the goal of this guide is that by the end – you will have all the knowledge and confidence necessary when completing your Form 5913. So let's get started!

Form NameTexas Form 5913
Form Length4 pages
Fillable fields0
Avg. time to fill out1 min
Other namesdads referral, CMA, Texas, dadsview

Form Preview Example

Texas Department of Aging

Form 5913

and Disability Services

August 2012-E

DADS Suspected Provider Fraud Referral

For Consumer Rights and Services (CRS) Use Only

Date Fraud Referral Received by CRS

Date Fraud Referral Sent to HHSC OIG

Fraud Referral Log Data Entry Completed By

CRS Fraud Referral Log No.

OIG Fraud Referral No.

Contact Information for DADS Staff Submitting Referral

Name of Staff











Title or Position




























































State Office

Region No.













Other (specify)

























DADS Office Street Address









Mail Code









ZIP Code
























Area Code and Telephone No.





Email Address

































Contact Information for Witness With Information About Suspected Fraudulent Activity


























Individual's Name











Area Code and Telephone No.




Relationship to Provider























Physical Address (Street, City, State, ZIP Code)







































Individual's Name











Area Code and Telephone No.




Relationship to Provider























Physical Address (Street, City, State, ZIP Code)










































Law Enforcement Agency Notified?


















Name of Law Enforcement Agency
















Date Notified



























Name of Individual Contacted











Title or Position
































Area Code and Telephone No.





Email Address











Case No.























Other Entity Notified? (i.e., Insurance Co., Bank, Subcontrator, etc.)




































Name of Entity


















Date Notified



























Name of Individual Contacted











Title or Position
































Area Code and Telephone No.





Email Address











Case No.




























Provider Information









































Name of Legal Entity (Owner)











Doing Business As (d.b.a.), if applicable

















Comp. Texas ID No. (TIN)

Contract No.


License No.


License Type


Facility ID No.




Provider Identifier No. (NPI/API)


















Physical Address (Street, City, State, ZIP Code)















Area Code and Telephone No.

















Business Mailing Address (P.O. Box or Street, City, State, ZIP Code)







Same as provider's physical address





























Physical Address Where Suspected Fraudulent Activity Occurred (Street, City, State, ZIP Code)



Same as provider's physical address










































Form 5913

Page 2 / 08-2012-E

Type of Provider


Adult Foster Care




Area Agencies on Aging


Intermediate Care Facilities


Assisted Living/Residential Care


Medically Dependent Children Program


CCAD Residential Care


Medicaid Administrative Claiming




ID Service Coordination


Client Managed Personal Attendant Services


Nursing Facilities


Consumer Directed Services


Out-of-Home Respite


Day Activity and Health Services


Performance Contract (with Local Authorities)


Deaf Blind with Multiple Disabilities



10 Emergency Response Services





Relocation Assistance Services

12 Home and Community-based Services



27 Texas Home Living


Home-Delivered Meals


Transition Assistance Services





Type of Suspected Fraudulent Activity

1 Billing Irregularities If Other, specify

2 Falsification/Alteration of Records

3 Trust Fund Irregularities

4 Other

Date or Date Range of Suspected Fraudulent Activity

Type of Review

Administrative Review

Investigation On Site

HCS/TxHml Certification Review

Trust Fund Monitoring

Billing and Payment

Investigation Desk Review

HCS/TxHml Follow-up Review


Formal Monitoring

Follow-up Investigation On Site

HCS/TxHml Intermittent Review


Follow-up Monitoring

Follow-up Investigation Desk Review

Regulatory Services Survey






Review Information

Review Period

Total Sample Size

Total Individuals Served




Was suspected fraudulent activity noted outside the sample or review period?




Was corrected action or recoupment requested as a result of this review?





Corrective Action


Other (specify)
















Amount due DADS as a result of this review



How much of this amount is suspected to be fraudulent?










Other Information (as of date of referral)

Has the provider received technical assistance on billing during the past two years?

Date(s) technical assistance was provided:




For HCSSA, Adult Day Care and Assisted Living licensed providers only, use the links below to enter the number of level B citations issued for the license associated with this contract.

http://dadsview.dads.state.tx.us/coo/contract/hcssadirectory.html or http://dadsview.dads.state.tx.us/coo/contract/adcalfdirectory.html

Number of Level B Citations:

OIG/OAG Investigator Only

For more information about skilled nursing facilities ratings score, go to the DADS Long Term Care Quality Reporting System (QRS) website at: http://facilityquality.dads.state.tx.us/qrs/public/qrs.do?page=geoArea&serviceType=nh&lang=en&mode=P&dataSet=1&ctx=807802

Regulatory Services Only

Compliance Review ID No.

Exit Date

Form 5913

Page 3 / 08-2012-E

Regulatory Services Only

Provide a detailed description of the suspected fraudulent activity.

Access to Care

If the provider's payments are suspended as a result of this referral and the provider must cease operations or significantly curtail services, would access to care be jeopardized for displaced individuals?

If yes, provide a detailed explanation below.


Form 5913

Page 4 / 08-2012-E

No Unknown

Suspension of Payments

Are you aware of any reason why the provider's payments should not be suspended or suspended only in part?

If yes, provide a detailed explanation below.



Regional and state office management: After reviewing the referral form, email form to Providerfraud@dads.state.tx.us.

OIG/OAG investigator: Contact COS at contractoversight@dads.state.tx.us if additional contract information is needed.

How to Edit Texas Form 5913 Online for Free

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With regards to the blanks of this specific PDF, here's what you need to do:

1. Whenever completing the how to make a referral to dads in dallas texas, make certain to incorporate all important blank fields in the relevant form section. This will help hasten the process, enabling your information to be processed fast and accurately.

Find out how to prepare recoupment step 1

2. Once your current task is complete, take the next step – fill out all of these fields - Law Enforcement Agency Notified, Yes, Name of Law Enforcement Agency, Date Notified, Name of Individual Contacted, Title or Position, Area Code and Telephone No, Ext, Email Address, Case No, Other Entity Notified ie Insurance, Yes, Name of Entity, Date Notified, and Name of Individual Contacted with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

recoupment writing process described (part 2)

Regarding Yes and Date Notified, be sure that you get them right in this current part. These are definitely the most important ones in this document.

3. In this particular step, take a look at Comp Texas ID No TIN Contract No, License No, License Type, Facility ID No, Provider Identifier No NPIAPI, Physical Address Street City State, Area Code and Telephone No, Business Mailing Address PO Box or, Physical Address Where Suspected, Same as providers physical address, and Same as providers physical address. All these should be taken care of with highest attention to detail.

Step number 3 in filling in recoupment

4. Filling out Type of Provider, Adult Foster Care, Area Agencies on Aging, Hospice, Intermediate Care Facilities, Assisted LivingResidential Care, Medically Dependent Children, CCAD Residential Care, CLASS CMA DSA SFS, Medicaid Administrative Claiming, ID Service Coordination, Client Managed Personal Attendant, Nursing Facilities, Consumer Directed Services, and Day Activity and Health Services is key in this stage - be sure to be patient and fill in each field!

Part # 4 of filling in recoupment

5. To finish your document, the last area involves some additional blanks. Completing Billing Irregularities, FalsificationAlteration of Records, Trust Fund Irregularities, Other, If Other specify, Date or Date Range of Suspected, Type of Review, Administrative Review, Investigation On Site, HCSTxHml Certification Review, Trust Fund Monitoring, Billing and Payment, Investigation Desk Review, HCSTxHml Followup Review, and Other will certainly conclude the process and you're going to be done in a short time!

Stage no. 5 in filling in recoupment

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