• Be completed by a licensed health care facility’s administrator, CEO, or other individual with authority to bind the facility listed;

• Include a valid email address for the individual with the authority to bind the facility;

• Include the license number of the facility;

• Contain the initials of the individual with authority to bind the facility certifying that: (1) each hospital facility listed will reserve at least 25% of its hospital capacity for treatment of COVID-19 patients, accounting for the range of clinical severity of COVID-19 patients and (2) each facility listed will not request any personal protective equipment from any public source, whether federal, state, or local, for the duration of the COVID-19 disaster;

• Not limit or qualify the above required certification language in any way;

• Be signed and dated by the facility’s administrator, CEO or other individual with authority to bind the facility;

• Be submitted via e-mail to HFLCertificationCoordinator@hhsc.state.tx.us; and

• Reference the name, license type and license number for each facility listed in the certification in the subject line of the email when submitting.