Get Texas X Ray Hardship Exemption Form

This guide provides a clear and detailed overview of how to complete the Texas X Ray Hardship Exemption Form online. Whether you are a hospital, federally qualified health center, or a practitioner, you will find step-by-step instructions that are easy to understand and follow.

Follow the steps to fill out the form successfully.

1. Click ‘Get Form’ button to obtain the form and open it in the online editor.
2. Enter the name of the applicant, which can be a practitioner or a hospital.
3. Indicate the type of applicant by circling the appropriate option: hospital, practitioner, or federally qualified health center (FQHC).
4. Provide the name and phone number of the contact person associated with the application.
5. Fill in the physical address where the radiologic procedures are performed, including city, state, and zip code.
6. Complete the mailing address section, including city, state, and zip code.
7. For FQHC or hospital applicants, enter the name of the supervising practitioner.
8. Specify the name of the relevant licensing board the practitioner belongs to (e.g., TSBME, TSBPE, TSBCE).
9. Input the hospital or practitioner’s license number and attach a copy of their license.
10. For FQHC applicants, include a copy of the current FQHC certification.
11. List the names of individuals who will perform x-rays.
12. Provide the approximate number of x-rays performed each week.
13. Describe the types of x-rays that will be performed.
14. Indicate whether pediatric core x-rays are performed and, if so, include who will perform these.
15. If required, attach the relevant sworn affidavits and any supporting documentation as outlined in the form.
16. Review your completed form to ensure all fields are accurately filled out.
17. Once finalized, save your changes, download a copy of the form, print it, or share it as needed.

Take action now by preparing your Texas X Ray Hardship Exemption Form online.