The purpose of this form is to furnish a standardized format for Home and Community Support Services Agencies (HCSSAs) to document their self-reported incident investigation summary, …

To be in compliance with regulatory requirements, you must submit the completed HHS Provider Investigation Report Form (Form 3613-A or 3613) according to your provider type.

Check here if individual or patient address below is a residential facility or in-patient hospice. If applicable, describe any special supervision required.

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(a) Enforcement.—The United States may enforce a judgment imposing a fine in accordance with the practices and procedures for the enforcement of a civil judgment under Federal law or State law.

Jul 15, 2025 · Flight status, tracking, and historical data for United 3613 (UA3613/UAL3613) including scheduled, estimated, and actual departure and arrival times.

After making a verbal report to 800-458-9858, submit Form 3613-A, Provider Investigation Report. Include statements and other relevant documentation, within the applicable regulatory time frame: five calendar days for ALFs, PPECCs and DAHS providers without ISS services.

Nice set of EMDs at DeCoursey Yd.

Jun 9, 2023 · HHSC published PL 2023-13 Changes to Initial Self-Reporting Methods and Provider Investigation Report Form 3613/3613-A. This PL reminds providers that the option to submit a self-reported incident via scripted voicemail …