Get Tx Dshs Form F25-11047 2020-2025

Filling out the TX DSHS Form F25-11047 ensures compliance with the Texas Health and Safety Code by summarizing your hospital's charity care policy and community benefits. This guide provides step-by-step instructions to complete the form online efficiently.

Follow the steps to successfully fill out the TX DSHS Form F25-11047.

1. Click ‘Get Form’ button to obtain the form and open it in your editing application.
2. Enter the facility identification number (FID) in the designated field using the 7-digit code from the attached hospital listing.
3. Fill in the name of the hospital, county, and both mailing and physical addresses if they differ.
4. Provide the effective date of the current charity care policy and the date of scheduled revision for this policy.
5. Indicate how often the charity care policy is reviewed.
6. Complete the section regarding the office and contact person for processing charity care requests, including the department name, contact person, phone number, title, fax, and email.
7. If you are not the person completing the form, provide your name and phone number.
8. In the charity care policy section, include your hospital's charity care mission statement.
9. Define 'charity care' as per your hospital's policy within the form.
10. Specify the percentage of federal poverty guidelines used for financial eligibility by checking the appropriate box.
11. Indicate whether eligibility is based on net or gross income by checking the appropriate option.
12. Specify if your hospital has a charity care policy for the medically indigent and provide the definition if applicable.
13. State whether an assets test is used to determine eligibility and summarize the method if applicable.
14. Describe whose income and resources are considered for determining eligibility using the provided options.
15. Identify which types of income are included in your definitions by checking all that apply.
16. Specify whether a completed application form is required for charity care requests, and provide details on how patients can request it.
17. Mention if application forms are available in locations other than the hospital and indicate if they are offered in languages other than English.
18. Detail the verification process and types of documentation required to process applications for charity care.
19. Specify when a patient is determined to be under the charity care policy.
20. Indicate how much of the bill will be covered under the charity care policy and whether there is a charge for processing applications.
21. Provide the time frame for completing the eligibility determination process and how long the eligibility lasts.
22. Explain how the hospital notifies patients about their eligibility for charity care.
23. Indicate whether all services are available to charity care patients and list any not covered if applicable.
24. Provide details about charity care services at hospitals owned by others and summarize current community benefits projects/activities.
25. Review all entered information for accuracy.
26. Once completed, save your changes, download, print, or share the form as needed.

Start filling out your TX DSHS Form F25-11047 online today to ensure compliance with the charity care requirements.