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