TX HHS Form 3646. Request for Formal Hearing

The TX HHS Form 3646, Request for Formal Hearing, is a crucial document that helps resolve disputes between facilities or agencies and the Texas Health and Human Services (HHS) department. This form is typically completed by an authorized representative of a facility or agency when they disagree with a proposed action taken by HHS, such as certification noncompliance, termination, or decertification.

The form requires specific information to be provided, including the name of the facility or agency, license holder, and street address. The request must also specify the type of hearing being sought, which can include certification noncompliance, proposed termination or decertification, administrative penalties, or termination of certification for Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID). Upon receipt of the form, HHS will notify the requesting party of the hearing date.

Key features of this form include the requirement to complete it accurately and submit it within specified timeframes. The authorized representative must also provide a brief statement explaining why they believe HHS's action is incorrect. The completed form should be submitted to Fairy Davenport Rutland, Director of the HHSC Appeals Division, at P.O. Box 149030, MC W-613 Austin, TX 78714-9030.

• This form is used when a facility or agency disagrees with a proposed action taken by HHS.
• The request must specify the type of hearing being sought and provide a brief statement explaining why the department's action is incorrect.
• Upon receipt of the form, HHS will notify the requesting party of the hearing date.