TX HHS Form 8614. Grievance Regarding Ombudsman Certification Decision

The TX HHS Form 8614, Grievance Regarding Ombudsman Certification Decision, is a crucial document for individuals who have been refused certification as a long-term care ombudsman or whose certification has been suspended or terminated. This form helps resolve disputes by providing a structured process for submitting grievances and supporting documentation.

To complete the form, users must provide their contact information, including name, area code and telephone number, home address, county of residence, ZIP code, and email address. They must also specify the decision they are submitting a grievance about (refusal, suspension, or termination) and list the reasons they disagree with the decision. Additionally, users may need to provide information from other individuals who can support their request, including their names and contact details.

Key features of this form include the requirement for users to affirm that the provided information is true and accurate, as well as the option to attach supporting documentation. The form also provides instructions on where to send the completed document ([email protected]) and how to contact the agency with questions (email or call 512-438-4265). By using this form, individuals can effectively address grievances related to ombudsman certification decisions.

• This form is used by individuals who have been refused certification as a long-term care ombudsman or whose certification has been suspended or terminated.
• The form requires users to provide their contact information and specify the decision they are submitting a grievance about.
• Users must list reasons they disagree with the decision and may need to provide information from other individuals who can support their request.