Get Tx F01-13066 2018-2025

The TX F01-13066 form is essential for obtaining an Emergency Medical Services Provider License in Texas. Filling it out correctly is crucial for compliance and successful application. This guide provides step-by-step instructions to assist you in completing the form online with ease.

Follow the steps to complete the TX F01-13066 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Select the application type. Indicate whether you are submitting an initial application, a renewal application, or another type.
3. Fill in the requested information, including your DSHS license number (if applicable), federal employer identification number, and national provider identifier number.
4. In Section 1, enter the legal entity name applying for the license.
5. If applicable, list all assumed or operating names in Section 2 and attach copies of any name certificates.
6. Complete Section 3 regarding vehicle names, providing explanations as needed.
7. Fill out Section 4 with information about the chief executive officer, owner, or highest elected official, including their contact details.
8. In Section 5, provide details for the administrator of record, ensuring accuracy in personal information.
9. Specify an alternate contact in Section 6 for inquiries if the administrator is not available.
10. In Section 7, include the designated infection control officer's details.
11. Fill out Section 8 with the physician medical director's name and contact information.
12. In Section 9, list the number of vehicle authorizations requested, categorizing by type.
13. Complete Sections 10 and 11, providing information on entity type, tax status, response type, subscription program, service area, and governmental recognition.
14. In Section 12, provide the headquarters' address and contact details, along with business hours.
15. Complete Section 14 regarding ownership and type of legal entity. Ensure all responsible person's details are accurately recorded.
16. Sign the form as required in Section 15, affirming the accuracy of the information provided.
17. Once completed, save changes, download the form, print it for records, or share it as necessary.

Complete your TX F01-13066 form online today to ensure your application is filed accurately and promptly.