Get Tx Dshs 11-15224 2022-2025

The TX DSHS 11-15224 form is essential for making changes related to the Texas Vaccines for Children (TVFC) and Adult Safety Net (ASN) programs. This guide will provide you with a step-by-step approach to completing the form online, ensuring that all necessary changes are accurately submitted.

Follow the steps to complete the TX DSHS 11-15224 online.

1. Click the ‘Get Form’ button to obtain the form and open it in your chosen online editor.
2. Begin by filling out Section A, which includes the original facility information. Provide the facility's PIN, today's date, original facility name, vaccine delivery address, city, county, and zip code.
3. Proceed to Section B if there is a change in facility name. Enter the new facility name, ensuring it adheres to the character limit and punctuation restrictions specified.
4. In Section C, if applicable, provide the new shipping address and ensure to include the city, county, and zip code.
5. For Section D, indicate the days and times your facility is available to receive vaccine shipments. Ensure compliance with the specified availability requirements.
6. Fill out Section E with the name, title, specialty, email address, medical license number, and Medicaid or NPI number of the new signing clinician.
7. In Section F, specify any changes to prescribing authorities. Include the names, titles, medical license numbers, and Medicaid or NPI numbers as necessary.
8. Section G requires documenting the patient population data changes. Accurately report the number of patients served by age group and eligibility category, based on the previous 12 months.
9. Continue in Section G to detail the insured and uninsured adults vaccinated at your facility within the previous year.
10. Section H involves recording any changes to the primary and/or backup vaccine coordinators. Include names, titles, email addresses, and telephone numbers.
11. After completing all sections, review the form for accuracy. Save your changes, download a copy, print, or share the form as needed.

Ensure you complete your documents online for efficiency and accuracy.