Form 3613-2025

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4.9 out of 5

41 votes

The document is a Provider Investigation Report for Home and Community Support Services Agencies, detailing the process for reporting allegations of abuse, neglect, or exploitation within home health, hospice, and personal assistance services. It includes sections for agency information, incident details, allegations, investigation findings, and required actions. The report emphasizes confidentiality and outlines the necessary steps for submitting the report to the Texas Department of Aging and Disability Services.

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Click ‘Get Form’ to open form 3613 in the editor.
Begin by filling in the 'Provider Use Only' section, including the date, fax number, and agency representative details.
In the 'Provider Investigation Report Information' section, enter your agency name, license number, address, and contact information accurately.
Complete the incident details by specifying the allegation type (abuse, neglect, exploitation) and providing a description of the incident.
Fill out client/patient information including their name, social security number, date of birth, and any relevant history.
Document findings from your investigation in the 'Investigation Summary' section and ensure all necessary signatures are included before submission.

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Versions	Form popularity	Fillable & printable
2009	4.9 Satisfied (41 Votes)
2008	4.3 Satisfied (163 Votes)

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