Get Tx Dshs 11-15224 2019

Filling out the TX DSHS 11-15224 form online is an important step for facilities participating in the Texas Vaccines for Children and Adult Safety Net Programs. This guide will provide you with comprehensive instructions to complete the form accurately and efficiently.

Follow the steps to fill out the TX DSHS 11-15224 form online.

1. Press the ‘Get Form’ button to access and open the TX DSHS 11-15224 form in your preferred document editor.
2. In Section A, complete the original facility information by entering the PIN (if applicable), today’s date, original facility name, vaccine delivery address, city, county, and zip code.
3. If there is a name change, move to Section B and provide the new facility name, ensuring that it does not include any disallowed punctuation.
4. Proceed to Section C to fill in the new signing clinician's details. Include their name, title, specialty, email address, medical license number, and Medicaid or NPI number.
5. In Section D, list the new prescribing authorities. Include their names, titles, medical license numbers, and Medicaid or NPI numbers.
6. In Section E, provide accurate data on patient population changes. Use the tables to document the number of children and adults vaccinated at your facility in the previous 12 months, categorized by their VFC or TVFC eligibility.
7. Review Section F, which contains the TVFC/ASN program agreement. The new signing clinician must read and sign the agreement to acknowledge understanding and compliance with all conditions outlined.
8. After completing all sections of the form, review the content for accuracy. Then, you can save changes, download the document, print it, or share it as needed.

Complete the TX DSHS 11-15224 form online to ensure your facility meets the necessary requirements.