Get Submit The Completed Form To The Appropriate - Dshs State Tx

This guide provides clear and detailed instructions for completing the Submit The Completed Form To The Appropriate - Dshs State Tx. By following these steps, you can ensure that your application is filled out correctly and submitted efficiently.

Follow the steps to complete your submission process online.

1. Press the ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin by entering the name of the legal entity applying for the license in Section 1. Ensure that this information is accurate and complete.
3. If applicable, provide the entity's assumed name in Section 2, and attach copies of all assumed name certificates.
4. In Section 3, fill out the Administrator of Record details, including the certification ID, name, mailing address, contact information, and check if the appropriate EMS Administrator of Record Form is attached.
5. Provide the Medical Director's information in Section 4, including their name, Texas License number, mailing address, and contact details.
6. In Section 5, denote the vehicle authorizations requested for various service levels by filling in the relevant fields.
7. Section 6 requires information about the entity type and response type. Check the appropriate boxes that apply to your organization.
8. For Section 7, attach a copy of a letter of credit if required, and fill in the institution name and date.
9. In Section 8, indicate whether a Medicaid Provider Surety Bond is required and provide additional information if necessary.
10. List the service areas in Section 9, providing cities and counties where operations will take place.
11. Section 10 asks for governmental recognition. List and attach any relevant recognitions from governmental entities.
12. Complete Section 11 with addresses for the headquarters, records location, and billing office, ensuring all information is available.
13. For Section 12, indicate the type of legal entity and ensure to notarize the document where required.
14. In Section 13, certify that the applicant and management team are not excluded from participation in Medicare and/or Medicaid programs.
15. Affirm your knowledge and experience in Section 14, and ensure to check the related box.
16. Section 15 requires you to sign and date the form, affirming the truthfulness of the information provided, and Section 16 needs a notary statement.
17. Finally, review all information for accuracy, and save changes before downloading, printing, or sharing the completed form.

Complete your documents online to ensure a smooth submission process.