Texas ems form 2026

1. Click ‘Get Form’ to open the Texas EMS Provider License Declaration Form in the editor.
2. Begin by selecting the application type: Initial Application, Renewal Application, or Other. Fill in your DSHS License Number if applicable.
3. In Section 1, enter the Legal Entity Name. Proceed to Section 2 to list any Assumed or Operating Names, attaching certificates if necessary.
4. Complete Sections 4 through 8 by providing details for the Chief Executive Officer, Administrator of Record, Alternate Contact, and Physician Medical Director respectively.
5. In Section 9, specify the number of vehicle authorizations requested at each level. Ensure all required fields are filled accurately.
6. Continue through Sections 10 to 15, checking appropriate boxes and providing necessary information about your entity type, insurance, and signatures.

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