Get Tx Dshs 11-15224 2021

The TX DSHS 11-15224 form is essential for facilities making changes to their enrollment in the Texas Vaccines for Children (TVFC) and Adult Safety Net (ASN) programs. This guide provides clear instructions for users to complete the form online with ease and confidence.

Follow the steps to effectively fill out the form online

1. Click 'Get Form' button to obtain the form and open it in the online editor.
2. Indicate the requested change by checking the appropriate box. Note that this form is to be used for changes to Facility Name, Signing Clinician, Prescribing Authorities, and Patient Population Data. Changes to facility address or coordinator do not require this form.
3. In Section A, complete the original facility information fields, including your Facility Name, Vaccine Delivery Address, and PIN. Ensure all details are accurate.
4. If you are changing the facility name, move to Section B and enter the New Facility Name, adhering to the character restrictions.
5. In Section C, provide the Name, Title, Specialty, Email Address, and Medical License Number of the new Signing Clinician.
6. Proceed to Section D if there are changes in Prescribing Authorities. Fill in the names, titles, and medical license numbers of any new prescribing authorities as needed.
7. In Section E, document Patient Population Data. Report the number of patients who have received vaccinations at your facility categorized by age group. Make sure to count patients accurately according to the guidelines provided.
8. In Section F, review the program agreement statements carefully. The new signing clinician must sign and date the form, agreeing to the outlined responsibilities related to vaccine administration and management.
9. After completing all sections, review the form for accuracy. Users can save changes, download, print, or share the completed form as required.

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