Form 3608 is an official planning and authorization document used in Texas Medicaid programs for individuals receiving services through Home and Community-based Services (HCS) and Community First Choice (CFC). The form documents an individual’s approved services, service levels, providers, and funding sources for a specific period of time, ensuring that care is appropriate, necessary, and compliant with state requirements.
Form 3613-A is an official Provider Investigation Report used in Texas to document and report incidents, allegations, and investigation findings involving individuals receiving care in regulated healthcare and long-term care settings. This form is submitted to the Texas Health and Human Services Commission (HHSC) and plays a critical role in regulatory oversight, resident protection, and compliance with state reporting requirements.
The “Informal Review Request” form (Form 3610, December 2020-E) is used by providers participating in the Texas Home Living (TxHmL) and Home and Community-based Services (HCS) waiver programs to request an informal review of findings issued by the Texas Health and Human Services Commission (HHSC). This document allows a provider to contest specific principles cited as noncompliant during an HHSC certification review. It serves as an official mechanism for providers to present additional documentation or clarification that may affect the final compliance determination.
Form 3622 serves as an official notification from the Texas Health and Human Services Commission (HHSC) informing individuals that their application for enrollment in the Community Living Assistance and Support Services (CLASS) Program has been denied. It outlines the reasons for denial and provides instructions on how to appeal the decision.
Form 3681 is used in Texas to apply for or update a Community Services Contract with the Health and Human Services Commission (HHSC). New and current providers use this form to submit legal entity information, request new contract types, and verify compliance with state and federal requirements.
This form is required for organizations and individuals who provide community-based services and need to:
The Texas Health Care Facility Certification Form 3221 (TX HHS Form 3221) is used to certify health care facilities under Executive Order GA-15. This form helps solve the problem of ensuring that licensed health care facilities comply with COVID-19-related restrictions on surgeries and procedures.
The TX HHS Form 3222, Confidentiality of Patient Records, helps facilities maintain the confidentiality of patient records as required by federal regulations. This form is used in situations where patient records need to be copied, removed, downloaded, or forwarded, ensuring that personal identifying information is protected.
Form 3223 is the official complaint form used in Texas to report concerns about the professional conduct of a Licensed Chemical Dependency Counselor (LCDC), Counselor Intern (CI), or a professional regulated by the Council on Sex Offender Treatment (CSOT). The form allows clients, family members, employers, or other involved parties to submit a written complaint for review by the Texas Health and Human Services Commission (HHSC).
The TX HHS Form 3224 is a Freestanding Emergency Medical Care Facility License Renewal Application designed to help facilities maintain their licensure status. This form is typically used by freestanding emergency medical care facilities seeking to renew their license with the Texas Health and Human Services (HHS) department.
The TX HHS Form 3226 is a crucial document for freestanding emergency medical care facilities seeking licensure in Texas. This application helps solve the problem of ensuring that these facilities meet specific standards and requirements to provide high-quality patient care. The form is typically used by facility owners or operators who need to obtain a license to operate their emergency medical care facility.
