Get Tx F01-13066 2017

Filling out the TX F01-13066 Emergency Medical Services Provider License Declaration Form online can seem daunting, but with careful attention to detail and guidance, the process can be straightforward. This guide will help you navigate each section of the form, ensuring that you provide the required information accurately.

Follow the steps to successfully complete the TX F01-13066 online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Select the appropriate application type by checking one of the options: Initial Application, Renewal Application, or Other. Provide a brief explanation if 'Other' is selected.
3. In the fill-in sections, complete the DSHS License Number, Federal Employer Identification Number, and National Provider Identifier Number. Leave the DSHS License Number blank if this is an initial application.
4. Under Section 1, provide the legal entity name applying for the license. This should be the official name of your organization.
5. In Section 2, list any assumed or operating names for your entity. Ensure to attach copies of any relevant certificates if applicable.
6. In Section 3, if your entity uses different names on vehicles, specify those names here along with a written explanation.
7. In Sections 4 and 5, provide the contact information for the Chief Executive Officer/Owner and the Administrator of Record, including their names, titles, addresses, and contact details.
8. List the alternate contact in Section 6, who can answer inquiries during the Administrator’s absence.
9. In Section 7, provide the name and contact information for the Designated Infection Control Officer.
10. Section 8 requires the name and contact details of the Physician Medical Director, including their medical license number.
11. In Section 9, indicate the number of vehicle authorizations you are requesting at each level and provide total authorizations.
12. Sections 10 and onwards involve various attestations regarding the entity's operations. Check the relevant boxes and complete any additional information as required.
13. Ensure you fill all supplemental sections accurately including ownership, insurance, business hours, and signatures as detailed in Sections 14 and 15.
14. Once completed, review the form for accuracy. You may save changes, download, print, or share the form as needed.

Start now to complete and submit your TX F01-13066 online application!