EMS LOA Request Form
To be completed for any Company requesting a Letter of Authorization from Harris County Commissioners Court.
Form Submitter Name
*
First Name
Last Name
Form Submitter Email
*
example@example.com
Form Submitter Phone Number
*
Please enter a valid phone number.
Business Owner Name
*
First Name
Last Name
Business Owner Email
*
example@example.com
Business Owner Phone Number
*
Please enter a valid phone number.
Business Name
*
Business DBA (if applicable)
Business Mailing Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Business Physical Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
State of Texas Taxpayer Identification Number
*
Medical Director's Name
*
First Name
Last Name
Medical Director's Email
*
example@example.com
Medical Director's Phone Number
*
Please enter a valid phone number.
Medical Director's License Number
*
Type of Medical Services to be provided?
*
Emergency - 911 Services (must attach letter of support from ESD Board)
Non-Emergency Services (must attach letter of need from an accredited non-emergency patient facility in unincorporated Harris County identifying need)
Both (both letters shall be attached)
Request for services is only within unincorporated Harris County?
*
Yes
No (this process is only for services in unincorporated Harris County)
Other areas in Texas currently authorized to provide medical services (if none, put N/A)
*
Attach Letter of Request to Harris County Commissioners Court
*
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For 911 Emergency Services: Attach Letter of Support from Emergency Services District Board
*
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For Non-Emergency Services: Attach Letter of Need from Patient Facility
*
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Any other supporting documents to be included in request.
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Signature verifying the information submitted is true and accurate.
*
Submit
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