Get Request For Informal Dispute Resolution Form - Texas.gov

Filling out the Request For Informal Dispute Resolution Form is essential for nursing facilities, intermediate care facilities, and assisted living facilities to dispute deficiencies with the Health and Human Services Commission. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to complete the form online

1. Press the ‘Get Form’ button to access the form and open it in the editing tool.
2. Select the type of facility from the 'Facility Type' section by checking the appropriate box: SNF/NF, ICF/IID, or ALF.
3. Indicate the type of informal dispute resolution by choosing one option from the 'IDR Type' section: Desk Review, Telephone Conference, or Face-to-Face Conference, noting that a one-hour meeting limit applies.
4. Fill in the facility name, facility ID, facility contact name and title, email address, mailing address, city, zip code, and telephone number in the provided fields.
5. Record the survey exit date, region, and the date received from form 2567/3724 in their respective sections.
6. If applicable, fill in the attorney or representative details, including their name, mailing address, telephone number, firm name, city, state, and zip code, ensuring that all correspondence will go directly to them.
7. List all deficiencies or violations disputed in the space provided using both federal and state tags when applicable. Users can add additional sheets as necessary.
8. Finally, enter your name and the date of submission in the 'Submitted by' section.
9. After completing the form, review all information for accuracy, then save changes, and consider downloading or printing the completed document for your records.

Complete your Request For Informal Dispute Resolution Form online today to ensure your disputes are handled promptly and effectively.