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- Click ‘Get Form’ to open the Texas EMS Provider License Declaration Form in the editor.
- Begin by entering the Legal Entity Name at the top of the form. This is essential for identification.
- Select whether this is an Initial Application, Renewal Application, or Other by checking the appropriate box.
- Fill in your DSHS License Number if applicable, and provide your Federal Employer Identification Number and National Provider Identifier Number.
- Complete Sections 1 through 8 with details about your organization, including names of key personnel and their contact information.
- In Section 9, list vehicle authorizations requested. Be specific about the types of vehicles you are applying for.
- Continue filling out Sections 10 through 15, ensuring all required attestations and signatures are completed accurately.
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