TX HHS Form 3639. Prescribed Pediatric Extended Care Center Informal Dispute Resolution Request

The Prescribed Pediatric Extended Care Center Informal Dispute Resolution Request (TX HHS Form 3639) is a crucial document for prescribed pediatric extended care centers (PPECCs) to resolve disputes in a timely and efficient manner. This form enables PPECCs to request an informal dispute resolution (IDR) process when faced with a statement of violations from the Texas Health and Human Services Commission.

To initiate the IDR process, PPECCs must submit this completed form, along with all supporting documentation, to HHSC within 10 calendar days after receiving a statement of violations. Key features of this form include listing disputed tags, U-tags, or enforcement actions, as well as providing a plan of correction in response to a statement of violations that cites a violation.

It is essential for PPECCs to carefully complete and submit this form to avoid denial of the IDR request. The form must be submitted with all required information and supporting documentation within the specified timeframe. By using this form, PPECCs can effectively resolve disputes and ensure compliance with regulatory requirements.

• This form is used by prescribed pediatric extended care centers (PPECCs) to request an informal dispute resolution (IDR) process.
• The form must be submitted within 10 calendar days after receiving a statement of violations from HHSC.
• PPECCs must list disputed tags, U-tags, or enforcement actions and provide a plan of correction in response to a statement of violations that cites a violation.