Get Service Area Designation - The Texas Department Of Aging And ... - Dads State Tx

Filling out the Service Area Designation form is a crucial step for entities seeking to provide specific services in Texas. This guide will walk you through the process, ensuring you understand each section and can complete the form effectively.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section 1, provide your legal entity information. Enter your region number, name of the legal entity, National Provider Identifier (NPI), catchment area name, contact person name, taxpayer identification number, and the area code and telephone number.
3. Proceed to Section 2 to list the service locations and areas. For each type of contract you intend to provide, fill in the corresponding details, including DADS license number (if applicable), name of the location, and the physical address, including street, city, state, and ZIP code. If you are providing services in multiple catchment areas, ensure you complete a separate form for each.
4. In Section 3, you will certify the information provided. Ensure accuracy by confirming that the details are true and correct. Sign the form as an authorized representative and include your printed name, date, and title.
5. Once all sections are completed, review the entire form for any necessary corrections. After confirming the form is filled out correctly, you can save your changes, download, print, or share the form as needed.

Complete your Service Area Designation form online today to move forward with your application.