How to Fill Out and Submit Texas Form 3613: Provider Investigation Report

Texas Form 3613 is the Provider Investigation Report that Home and Community Support Services Agencies file with the Texas Health and Human Services Commission after investigating an alleged abuse, neglect, or exploitation incident involving a client. The completed form, with every supporting document attached, must reach HHSC no later than the tenth day after your agency made its initial oral report of the incident.1Texas Health and Human Services Commission. Form 3613, Provider Investigation Report with Fax Cover Sheet This guide walks through who files it, how to complete each section, where to send it, and what happens afterward.

Who Files Form 3613

Form 3613 is for Home and Community Support Services Agencies (HCSSAs) only: home health agencies, hospice providers, and personal assistance services providers licensed under Texas Health and Safety Code Chapter 142.1Texas Health and Human Services Commission. Form 3613, Provider Investigation Report with Fax Cover Sheet

If you operate a nursing facility, skilled nursing facility, ICF/IID, assisted living facility, day activity and health services provider, or prescribed pediatric extended care center, you use Form 3613-A instead. That form has different deadlines and a different field set, so submitting the wrong one will slow your filing down.2Texas Health and Human Services Commission. Form 3613-A, SNF, NF, ICF/IID, ALF, DAHS including ISS providers and PPECC Provider Investigation Report with Cover Sheet

The Ten-Day Clock Starts With the Oral Report

The written investigation report is step two. Step one happens the moment someone at the agency believes a client has been abused, neglected, or exploited by an employee. Under 26 TAC ยง558.249(c), the agency must call HHSC Complaint and Incident Intake at 1-800-458-9858 within 24 hours.3Texas Health and Human Services. HCSSA FAQs That oral report is what starts the Form 3613 clock. You have until the tenth day after the call to get the completed report, with all statements and documentation, to HHSC. If you mail it, the envelope must be postmarked by that tenth day.1Texas Health and Human Services Commission. Form 3613, Provider Investigation Report with Fax Cover Sheet

When you make the oral report, HHSC issues an Intake ID number. Write it down. You will need it on every page of the written report, including the fax cover sheet and every attachment. Without that number, HHSC cannot match the paperwork to the complaint on file.

The incidents that require a report cover a broad range of conduct. Texas regulations define the categories this way:

  • Abuse is the willful or negligent infliction of injury, unreasonable confinement, intimidation, or cruel punishment causing physical or emotional harm, along with sexual abuse by a caretaker or other individual with an ongoing relationship to the person.4Legal Information Institute (LII) / Cornell Law School. Abuse, Neglect, and Exploitation Defined
  • Neglect is a caretaker’s failure to provide goods or services, including medical services, necessary to avoid physical or emotional harm.4Legal Information Institute (LII) / Cornell Law School. Abuse, Neglect, and Exploitation Defined
  • Exploitation is an illegal or improper act by a caretaker, family member, or other individual using an elderly or disabled person’s resources for personal benefit without informed consent.4Legal Information Institute (LII) / Cornell Law School. Abuse, Neglect, and Exploitation Defined

The definitions also carve out conduct that does not qualify as abuse: proper use of restraints under a lawful order, reasonable force used to prevent imminent harm, and complaints about routine administrative issues such as staffing levels.

Filling Out the Form

Download the current version of Form 3613 from the HHSC website before you start. Mark the HHSC Intake ID on every page as you go, not at the end.

Agency and Incident Details

The opening section asks for your license number, agency name, physical address, and contact information. Below that, enter the date and time the alleged incident occurred, the date and time it was first reported to your agency, and how it was discovered. Specifics matter here. Vague entries slow down processing and tend to generate follow-up requests from HHSC.

Alleged Victim and Alleged Perpetrator

Give the client’s full name and identifying details. For the alleged perpetrator, the form covers current and former employees, contractors, and volunteers, including family members paid by the agency to provide services to the client. When neither the client nor the agency can name the person, describe them as completely as possible.

You also need to attach documentation of your pre-employment and ongoing screening of the alleged perpetrator: criminal history check results, Nurse Aide Registry search results, and Employee Misconduct Registry search results.1Texas Health and Human Services Commission. Form 3613, Provider Investigation Report with Fax Cover Sheet HHSC-regulated providers must check both registries before hiring and annually afterward; a hit on either for abuse, neglect, exploitation, or misappropriation of property makes the person unemployable at any HHSC-regulated agency.5Texas Health and Human Services. Employee Misconduct Registry (EMR) The attachments show you did your part.

Injury Description and Treatment

Describe any physical or emotional assessment performed in response to the incident. If the client received medical treatment, record the date, time, and location. Keep this section factual and clinical: what was observed, who performed the assessment, and what care was provided.

Immediate Agency Response

Describe every protective action the agency took after the allegation surfaced. That includes staffing changes to keep the alleged perpetrator away from the client, medical evaluations ordered, and notifications to the client’s physician, family, or legal guardian. If you reported the incident to the Department of Family and Protective Services, include the DFPS call or case number. If law enforcement responded, include the police case number and the responding officer’s name.1Texas Health and Human Services Commission. Form 3613, Provider Investigation Report with Fax Cover Sheet

Investigation Summary

This is the heart of the report. HHSC reviewers apply a preponderance-of-the-evidence standard, looking at which side the more convincing evidence favors rather than the volume of documents attached.6Texas Health and Human Services. Evidence Collection Your summary should reflect the same approach.

Write it concisely, factually, and objectively. Summarize your analysis of the supporting documents: interviews, witness statements, injury reports, diagrams, observations, and any other evidence. State your conclusion about the allegation. State separately whether any agency practices contributed to the incident. Then give your recommendations and explain how you reached each conclusion.1Texas Health and Human Services Commission. Form 3613, Provider Investigation Report with Fax Cover Sheet A one-line summary like “the allegation could not be substantiated,” with no reasoning, invites a state follow-up investigation.

What To Attach

The form on its own is not a complete report. Attach every piece of evidence that supports your findings:

  • Witness statements, typed or clearly transcribed, and signed by the witness when possible.
  • Background check documentation: criminal history, Nurse Aide Registry, and Employee Misconduct Registry results for the alleged perpetrator.
  • Medical records, including treatment logs, skin grids, physician notes, and post-incident assessments.
  • Photographs of injuries or related environmental conditions.
  • Law enforcement records: report numbers and responding officer names if local law enforcement was involved.

Count the pages before you choose a submission method. The total page count determines which channels are open to you.

How To Submit

HHSC accepts Form 3613 through four channels. The size of your package decides which ones you can use.

  • Email, for packages of 15 pages or fewer: ciiprovider@hhs.texas.gov.
  • Fax, for packages of 15 pages or fewer: 1-877-438-5827 (toll-free).
  • Mail, for packages of 16 pages or more: Texas Health and Human Services Commission, Regulatory Services, Complaint and Incident Intake, Mail Code E-249, PO Box 149030, Austin, TX 78714-9030. Postmark by the tenth day.
  • TULIP, the Texas Unified Licensure Information Portal, for online submission with your HHSC Intake ID.7Texas Health and Human Services. Changes to Initial Self-Reporting Methods and Provider Investigation Report Form 3613/3613-A

Keep proof of submission no matter which method you use. Print the fax transmission confirmation. Save the sent email and any read receipt. Use certified mail or another trackable service for mailed packages. If HHSC later questions whether you met the ten-day deadline, that confirmation is your defense.1Texas Health and Human Services Commission. Form 3613, Provider Investigation Report with Fax Cover Sheet Keep a complete copy of the form, every attachment, and the delivery proof in your agency files for future audits.

What HHSC Does With the Report

A Provider Investigations reviewer at HHSC reads the report and evaluates whether your internal investigation and conclusions hold up under the preponderance-of-the-evidence standard. The state can confirm the allegation, find it unconfirmed, call it inconclusive if the evidence does not point either way, or find it unfounded as false or without factual basis.8Texas Health and Human Services. Investigation Completion

During the review, HHSC may ask for more documentation, show up for an unannounced on-site survey, or launch its own independent investigation. The agency is notified when the case closes or when further action is required. If HHSC issues a Statement of Deficiencies, your agency has ten calendar days to request Informal Dispute Resolution.9Texas Health and Human Services. Informal Dispute Resolution Process

What Happens If You Miss the Deadline

The consequences run on two tracks. For the agency, HHSC can assess a $500 administrative penalty per violation for certain compliance failures, including failing to submit a required plan of correction, without first giving the agency an opportunity to correct.10Legal Information Institute (LII) / Cornell Law School. 26 Texas Administrative Code 558.602 – Administrative Penalties Repeated or serious violations can lead to larger enforcement actions, up to license revocation. The financial penalty is modest; the licensing scrutiny that follows is the real cost.

For individuals, Texas Human Resources Code 48.051 requires any person with cause to believe an elderly or disabled person is being abused, neglected, or exploited to report to HHSC, regardless of whether the knowledge came through employment or otherwise confidential communications.11State of Texas. Texas Human Resources Code 48.051 – Report Knowingly failing to report is a Class A misdemeanor, punishable by a fine up to $4,000, up to one year in jail, or both.12State of Texas. Texas Penal Code 12.21 – Class A Misdemeanor Good-faith reporters are protected from civil and criminal liability, so the legal exposure runs toward silence, not disclosure.