TX HHS Form 3613. Provider Investigation Report with Fax Cover Sheet (Home Health. Hospice and Personal Assistance Services Provider Use Only)

The TX HHS Form 3613, Provider Investigation Report with Fax Cover Sheet, is a crucial tool for home health, hospice, and personal assistance services providers in Texas. This form helps resolve complaints and incidents related to these services by providing a standardized framework for reporting and investigating issues.

The report requires essential information such as the date of the incident, the name and title of the agency representative, and the reporter's email address. Additionally, it includes a fax cover sheet with details like the area code and phone number, as well as instructions on how to submit the report via email or fax. The form also emphasizes the importance of confidentiality, warning recipients that any unauthorized disclosure is strictly prohibited.

This form is designed for providers to use when investigating incidents or complaints related to their services. Key features include the requirement for a unique intake ID number and the provision of contact information for follow-up actions. By using this standardized report, providers can ensure compliance with regulations and maintain transparency in their operations. Some key points to note are:

• The form is intended for home health, hospice, and personal assistance services providers in Texas.
• It is used to investigate incidents or complaints related to these services.
• The report requires essential information such as date, agency representative details, and reporter's email address.