Follow the steps to successfully complete your application

1. Press the ‘Get Form’ button to access the TX DSHS Uncompensated Trauma Care Application. This will allow you to open and begin working on the form.
2. Complete Part A of the application by entering your facility name, license number, mailing address, and contact information. Make sure to provide the Texas Provider Identifier and National Provider Identifier numbers.
3. Indicate the current designation status of your facility. If applicable, ensure you specify if your facility is in active pursuit of designation.
4. Enter the total number of patients documented in the Trauma Registry and the number of trauma team activations throughout the specified timeframe.
5. Fill in the total number of emergency department visits, as well as the uncompensated trauma care charges, detailing sums categorized as charity care or bad debt according to your hospital’s policy.
6. Move to Part B of the application, which requires signatures from the Chief Executive Officer, Chief Financial Officer, and the Chairman of the Board of Directors. Obtain notary verification for each signature to ensure compliance.
7. In Part C, submit supporting data that matches the information provided in Part A. This data should include detailed accounts and claims for uncompensated trauma care.
8. Review all entries to ensure accuracy. Check that all required fields are completed before submitting your application.
9. Once all sections are filled out, save your changes. You can then download a copy of the application, print it for your records, or share it as needed.

Complete the TX DSHS Uncompensated Trauma Care Application online to ensure your facility is considered for funding.