VR3118 Hospital/Medical Service Areas



Texas Workforce CommissionVocational Rehabilitation ServicesHospital Facility Information FORMTEXT ?Instructions: FORMTEXT ?For response to an Electronic State Business Daily (EBSD) posting, follow the instructions in the ESBD posting. FORMTEXT ? All sections must be completed at application. FORMTEXT ?Type all information on form using a computer and get all required handwritten signatures. FORMTEXT ? FORMTEXT ?Complete all sections of the form. Record “N/A” (not applicable) if a question does not apply. FORMTEXT ? Keep a copy of your submitted form with attachments and supporting documentation for your records. FORMTEXT ?Reason for Submission FORMTEXT ? Date of submission: FORMTEXT ?????Solicitation ID: FORMTEXT ????? FORMCHECKBOX Application package FORMCHECKBOX Update of information due to change in information on file. For example, qualifications change. FORMCHECKBOX Other: Specify: FORMTEXT ?????Hospital System Information FORMTEXT ? Hospital System: The business that is requesting or has been granted the bilateral contract with TWC to provide services on behalf of VR customers. FORMTEXT ?Hospital System’s legal name: FORMTEXT ????? Hospital System’s “doing business as” (DBA) name: FORMTEXT ?????Physical address: FORMTEXT ?????City: FORMTEXT ?????County: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Mailing address: (if different from physical address) FORMTEXT ?????City: FORMTEXT ?????County: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Email address, if any: FORMTEXT ?????Web address (if applicable): FORMTEXT ?????Provide the following: Medicare Number: FORMTEXT ?????NPI Number: FORMTEXT ?????Primary Contact for Contract Purposes FORMTEXT ?Last name: FORMTEXT ?????First name: FORMTEXT ?????Title: FORMTEXT ?????Direct Phone number:( FORMTEXT ???) FORMTEXT ?????Alternate phone number:( FORMTEXT ???) FORMTEXT ?????Fax number:( FORMTEXT ???) FORMTEXT ?????Email address: FORMTEXT ?????Primary Contact for Billing Purposes FORMTEXT ?Last name: FORMTEXT ?????First name: FORMTEXT ?????Title: FORMTEXT ?????Direct Phone number:( FORMTEXT ???) FORMTEXT ?????Alternate phone number:( FORMTEXT ???) FORMTEXT ?????Fax number:( FORMTEXT ???) FORMTEXT ?????Email address: FORMTEXT ?????Hospital Location(s) FORMTEXT ? (Submit a VR3118 for each hospital location)Hospital’s legal name: FORMTEXT ?????Hospital’s “doing business as” (DBA) name: FORMTEXT ?????Physical address: FORMTEXT ?????City: FORMTEXT ?????County: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Phone number:( FORMTEXT ???) FORMTEXT ?????Fax number:( FORMTEXT ???) FORMTEXT ?????Provide the following: Medicare Number: FORMTEXT ?????NPI Number: FORMTEXT ?????Available Services FORMTEXT ?Check all that apply: FORMCHECKBOX Hospital Services: FORMCHECKBOX Inpatient Service FORMCHECKBOX Outpatient Services FORMCHECKBOX Implantable Device: FORMCHECKBOX Implanted FORMCHECKBOX Embedded FORMCHECKBOX Inserted FORMCHECKBOX Otherwise FORMCHECKBOX Related equipment necessary to operate, program and recharge the implantable FORMCHECKBOX Medical Records FORMCHECKBOX Robotic SurgeryTWC Acknowledgment and Signatures FORMTEXT ?This acknowledgment is applicable to, and shall be considered active for, the following purposes: FORMTEXT ?Processing of the respondent’s application; FORMTEXT ?Execution of the initial award, if applicable; FORMTEXT ?Continuation of the contract life through subsequent execution of renewals and/or amendments and/or FORMTEXT ? updating information on file with TWC as applicable. FORMTEXT ? I, the legally authorized representative, have been named by the entity and have the authority to certify: FORMTEXT ?the entity has the ability to provide Hospital/Medical services in Texas; FORMTEXT ?the information provided in this form is complete and accurate, and FORMTEXT ?the legal entity is in compliance with all the terms in the Electronic State Business Daily (ESBD) Agency Posting notice, and/or contract if awarded. FORMTEXT ? Legally authorized representative’s printed name: FORMTEXT ?????Title: FORMTEXT ?????Legally authorized representative’s handwritten signature:X FORMTEXT ?Date: FORMTEXT ?????Agency Use Only FORMTEXT ?Comments, if any: FORMTEXT ?????Reviewers of the Form FORMTEXT ?DatePrinted NameTitleSignatureInitials FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? ................
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