TX HHS Form 3646. Request for Formal Hearing

The TX HHS Form 3646, Request for Formal Hearing, is a crucial document used to initiate a formal hearing process when an individual or organization disagrees with a decision made by the Texas Health and Human Services (HHS) regarding the certification of a nursing facility or the termination/suspension of a facility or agency license. This form must be completed accurately, signed, and submitted within specific timeframes.

The form requires the following information: name of facility or agency, survey exit date, street address or P.O. box, city, state, and ZIP code; name of license holder; type of facility or agency; and a brief statement explaining the basis for contending that the department's action is incorrect. The form also includes sections for requesting a formal hearing on specific issues, such as certification of noncompliance, proposed termination or decertification, administrative penalties, or termination of certification.

This form should be used when an individual or organization wants to appeal a decision made by HHS regarding the certification of a nursing facility or the termination/suspension of a facility or agency license. The completed form must be submitted to Fairy Davenport Rutland, Director HHSC Appeals Division, at P.O. Box 149030, MC W-613 Austin, TX 78714-9030, with area code and fax number 512-231-5779 and phone number 512-231-5701.