Get Confirmation Form For Providing Emergency 911 Or Emergency ... - Dshs State Tx

Completing the Confirmation Form for Providing Emergency 911 or Emergency Transfer Service is essential for licensed EMS providers seeking funding in jurisdictions outside their county of licensure. This guide will offer you clear instructions on how to effectively fill out this form online, ensuring compliance with the necessary documentation requirements.

Follow the steps to complete the confirmation form accurately

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the provider's name and license number in the designated fields. Ensure that the information is correct and corresponds with the records held by the relevant licensing authority.
3. Indicate the county of licensure and the Trauma Service Area (TSA). It is crucial to select the correct TSA to avoid processing delays.
4. In the Level of Service section, specify the type of emergency service being provided to ensure it aligns with funding eligibility criteria.
5. Provide documentation in the form of a Contract or Letter of Agreement if applicable. If eligibility is based on a geo-political subdivision crossing county lines, ensure you cite this accurately.
6. Fill in the licensed provider name in the agreement acknowledgment section, along with the city and/or county where the service is being provided.
7. Record the validity period of this agreement by entering the start and end dates in the specified fields.
8. If applicable, list any geo-political subdivisions that do not require a contract or letter of agreement. Confirm this listing with a City, County, or Municipal Official.
9. Ensure that both the Administrator and the City/County/Municipal Official print and sign their names on the form. Double-check for signatures and printed names before proceeding.
10. Finally, fax the completed form to the EMS/Trauma Systems Coordination Office at the specified number, 512/834-6611. Make sure to save any copies for your records.

Complete your documentation today and ensure compliance for seamless emergency service operation.