TX HHS Form 3628. Provider Agency Model Service Backup Plan

The TX HHS Form 3628, Provider Agency Model Service Backup Plan, is a crucial document that helps service providers develop a contingency plan in case of an absence or emergency. This form ensures that essential services are maintained, and clients receive continued support.

This form requires the provider agency to provide specific information, including the name of the individual program, type of service, and date of service planning team meeting. The backup plan must outline strategies for service delivery, including a sequence of actions to be taken in the absence of a resource person. Additionally, the form includes spaces for signatures from the service planning team members, provider agency representative, and case manager.

The TX HHS Form 3628 is typically used when a provider agency needs to develop a backup plan for its services. This could include situations where an employee is absent due to illness or vacation, or in the event of an unexpected emergency that affects service delivery. By completing this form, provider agencies can ensure that they are prepared to respond quickly and effectively in the event of an absence or emergency.