TX HHS Form 3610. Informal Review Request

The “Informal Review Request” form (Form 3610, December 2020-E) is used by providers participating in the Texas Home Living (TxHmL) and Home and Community-based Services (HCS) waiver programs to request an informal review of findings issued by the Texas Health and Human Services Commission (HHSC). This document allows a provider to contest specific principles cited as noncompliant during an HHSC certification review. It serves as an official mechanism for providers to present additional documentation or clarification that may affect the final compliance determination.

Purpose of the Form

Providers use this form when they disagree with a finding of noncompliance identified in HHSC’s draft or final review results. The informal review request gives them the opportunity to explain the rationale for contesting the finding, submit evidence previously shown to reviewers, and ensure that all relevant information is considered before HHSC finalizes enforcement outcomes.

Who Should Use This Form

Form 3610 is intended for:

• TxHmL program providers
• HCS program providers
• Program managers and chief executive officers responsible for regulatory compliance

Any provider seeking reconsideration of a cited principle must complete and submit this form separately for each principle they believe was misinterpreted, incorrectly cited, or insufficiently supported by the review findings.

Situations When the Form Is Required

A provider should submit this document when:

• They have received a final report identifying principles out of compliance.
• They believe a principle was incorrectly cited during the certification, follow-up, annual, or intermittent review.
• They have supporting evidence that was presented during the review but not fully considered.
• They wish to challenge the citation of a critical violation.

All informal review requests must be submitted within 10 calendar days of receiving the final HHSC report.

Main Sections of the Form

Provider Information

This section collects identifying details about the provider, including:

• Provider name
• Component code
• Contract number
• Applicable waiver program (TxHmL or HCS)

Type of Review

The form allows the provider to specify the type of HHSC review in question:

• Annual/Initial Certification
• Follow-up Review
• Intermittent Review

The provider must also indicate whether the cited issue involved a critical violation.

Date of Exit

The date on which the certification review team completed their onsite or virtual exit meeting must be entered here.

Principle in Noncompliance

The provider must list the specific principle number that was cited as noncompliant. This ensures HHSC reviews the correct item during the informal review process.

Rationale for Informal Review Request

In this section, the provider explains why they believe the noncompliance finding should be reconsidered. Acceptable rationales may include:

• Evidence that supports compliance but was not fully considered
• Clarification of documentation provided during the review
• Misinterpretation of facts or program requirements

Signatures

Both the Program Manager and the Chief Executive Officer must sign and date the form. These signatures certify the accuracy of the information and authorize submission to HHSC.

Submission Requirements

To request an informal review, the provider must:

• Submit one form for each principle being contested.
• Attach all relevant supporting documentation that was presented during the original review.
• Ensure HHSC receives the request within 10 days of receiving the final report.

Completed documents should be sent to:

Texas Health and Human Services Commission
Regulatory Services
Survey and Certification Enforcement Unit
701 W. 51st Street, Mail Code E-351
Austin, TX 78751

If the total documentation is fewer than 50 pages, providers may fax the submission to: 512-438-4138.

Form Details

• Form Name: Informal Review Request
• Form Number: 3610
• Program: TxHmL / HCS (Texas)
• Issued by: Texas Health and Human Services Commission (HHSC)
• Edition Date: December 2020-E