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

The TX HHS Form 3639, Prescribed Pediatric Extended Care Center Informal Dispute Resolution Request, is a crucial document that enables prescribed pediatric extended care centers (PPECCs) to request an informal dispute resolution (IDR) process. This form should be used when a PPECC receives a statement of violations from the Texas Health and Human Services Commission (HHSC) and wishes to dispute certain tags, U-tags, or enforcement actions.

The key features of this form include the required information section, where the PPECC must list the specific tags, U-tags, or enforcement actions they wish to dispute. The form also specifies that HHSC must receive the PPECC's IDR request and supporting documentation within a certain timeframe (no later than the 10th calendar day after receiving the statement of violations) or the IDR request will be denied. Additionally, the form notes that a PPECC must submit a plan of correction in response to a statement of violations that cites a violation, even if they disagree with the survey results.

This form is essential for PPECCs to resolve disputes and ensure compliance with HHSC regulations. By submitting this completed form and supporting documentation, PPECCs can initiate an IDR process and work towards resolving any outstanding issues. The TX HHS Form 3639, Prescribed Pediatric Extended Care Center Informal Dispute Resolution Request, is a vital tool for PPECCs to maintain compliance and continue providing quality care to their patients.