TX DSHS 11-15224 2019 free printable template
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Texas Vaccines for Children (TFC) and Adult Safety Net (ASN) Program Changes to Enrollment Form DIRECTIONS This form is required when TFC/ASN sites have changes to: Facility Name Sections A & B Signing
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How to fill out TX DSHS 11-15224
How to fill out TX DSHS 11-15224
01
Obtain the TX DSHS 11-15224 form from the Texas Department of State Health Services website or your local health department.
02
Fill in the applicant's name, including last name, first name, and middle initial in the designated fields.
03
Provide the applicant's date of birth in the specified format (MM/DD/YYYY).
04
Enter the applicant's address, including street number, street name, city, state, and zip code.
05
Include a contact phone number and email address for the applicant.
06
Complete the section regarding the purpose of the form, indicating the specific program or service it pertains to.
07
Review and sign the declaration statement ensuring all information is accurate.
08
Submit the completed form according to the instructions provided (in person, by mail, or electronically as applicable).
Who needs TX DSHS 11-15224?
01
Individuals or families seeking assistance or services from the Texas Department of State Health Services.
02
Community organizations working on behalf of clients to access health services.
03
Healthcare providers needing to refer patients for specific programs or services.
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What is TX DSHS 11-15224?
TX DSHS 11-15224 is a form used by the Texas Department of State Health Services for reporting specific health-related data.
Who is required to file TX DSHS 11-15224?
Entities or individuals required to file TX DSHS 11-15224 typically include healthcare providers, facilities, and organizations involved in public health reporting.
How to fill out TX DSHS 11-15224?
To fill out TX DSHS 11-15224, download the form from the Texas DSHS website, ensure you have all required information, complete the sections accurately, and submit it following the specified submission guidelines.
What is the purpose of TX DSHS 11-15224?
The purpose of TX DSHS 11-15224 is to collect vital health information that aids in monitoring public health trends and implementing health interventions.
What information must be reported on TX DSHS 11-15224?
The information that must be reported on TX DSHS 11-15224 generally includes demographic details, health conditions, and any relevant medical history related to the report.
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