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This form furnishes a standardized format for long-term care (LTC) providers to document their self-reported incident investigation summary, analysis and finding(s) per regulatory requirements. Procedure. After making a verbal report to 800-458-9858, submit Form 3613-A, Provider Investigation Report.
Provider Investigation Report Form 3613-A October 2008 Fax this report to: 1-877-438-5827 (toll free) Note to reporter: Do not mail if faxed. or Mail this report to: Texas Department of Aging and Disability Services, Consumer Rights and Services Section, E-249, P.O. Box 149030, Austin, TX 78714-9030
Form 3613-A Provider Investigation Report must also be completed and submitted within five days from the day a confirmed case is reported to CII. The provider investigation report can be submitted: via TULIP. by email at ciiprovider@hhs.texas.gov; or. by fax at 877-438-5827.
Home and Community Support Services Agency. Provider Investigation Report. (Home Health, Hospice and Personal Assistance Services Provider Use Only) Form 3613. October 2023. Fax this report to (if 15 total pages or fewer): 877-438-5827. Email this report to: ciiprovider@hhs.texas.gov.
1 Μαρ 2023 · Download Fillable Form 3613-a In Pdf - The Latest Version Applicable For 2024. Fill Out The Snf, Nf, Icf/iid, Alf, Dahs Including Iss Providers And Ppecc Provider Investigation Report With Cover Sheet - Texas Online And Print It Out For Free.
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Provider Investigation Report (PIR): The PIR (Form 3613-A/3613) is an expansion of the initial incident details documented after the investigation is complete. This report includes a provider's summary of the investigation process and findings, as well as details on your post-investigation actions as a provider.
