Welcome to the Texas Health and Human Services (HHS) Complaint & Incident Intake (CII) On-line Provider Incident Self-Report Application.
The On-line Provider Incident Self-Report Application allows HHS providers to self-report incidents in lieu of calling the HHS toll-free line (800-458-9858) and reporting via the voicemail incident form application or speaking with an intake specialist.
This application is intended for providers to report details of a reportable incident necessary to meet the oral regulatory reporting requirements and is NOT intended for providers to report details unique to the facility investigation of the incident.
To be in compliance with regulatory requirements, you must fax, mail or email a completed HHS Provider Investigation Report Form as outlined in your provider service type Incident Reporting Guidelines (Section beginning: How can a provider determine if an incident is reportable?)
The provider investigation report form along with statements and other relevant documentation needs to be submitted within the applicable regulatory time frame:
Form 3613-A, SNF, NF, ICF/IID, ALF, ADC, DAHS and PPECC Provider Investigation Report with Cover Sheet is to be used by nursing facilities, day activity and health service providers, assisted living facilities and private intermediate care facilities.
Form 3613, Provider Investigation Report with Fax Cover Sheet (Home Health, Hospice and Personal Assistance Services Provider Use Only) is to be used by home health and hospice agencies.
The form needs to be signed and providers who fax the form must use the dedicated fax coversheet.
If the HHS Provider Investigation Report form with statements and other relevant documentation is 15 pages or fewer, fax the report and attachments toll-free to HHS at 877-438-5827.
Backup fax numbers are 512-438-2722 or 512-438-2724.
You also may email the completed provider investigation report to email@example.com. (Attachments must be less than 20 MB.)
If the report and other relevant documentation is 16 pages or more, mail the report and attachments to:
Texas Health and Human Services
Complaint & Incident Intake Unit
Mail Code E-249
P.O. Box 149030
Austin, TX 78714-9030
Either fax, mail or email the report and any attachments, based on the length of the report.
A separate Form 3613 or 3613-A must be completed and submitted for each incident reported.
You will need your facility/agency license ID # to start your report.
There are several required fields which must be completed before you can submit your provider incident report. Links to continue to the next page or to go back to the previous page will be provided.
Narrative sections will have maximum character limits and the application will "timeout" after 20 minutes of inactivity if the application is open and the incident not successfully transmitted.
A confirmation number will be provided when the incident has been successfully transmitted.
This unique incident tracking number should be referenced on your Provider Investigation Report Form. See the section beginning: How soon does a provider need to complete and submit their provider investigation report and where is the report sent? on the Provider Self-Reporting page.
Be sure to print a copy of the confirmation page for your records.
NO additional contact from HHS intake staff will occur when you use the on-line application. HHS intake staff would only contact you if additional clarification or more details are needed regarding the incident to complete triage and prioritization of the intake.
This option is not for the general public to report a complaint or request program information. If you are seeking information or wish to file a complaint, please call 1-800-458-9858 or email firstname.lastname@example.org. If you are a HHS provider, please continue.