Get Provider-information-change-form (2).pdf - Tmhp.com

This guide provides clear instructions on how to successfully complete the Provider-Information-Change-Form (2).pdf. By following these steps, you can efficiently update your provider enrollment information.

Follow the steps to fill out the Provider-Information-Change-Form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editor.
2. Fill in your 9-digit Texas Provider Identifier (TPI) at the top of the form. Include the date and your full provider name.
3. If applicable, list any additional TPIs that share the same provider information in the designated area.
4. Complete the Physical Address section, being sure to use a valid address and not a P.O. Box. Provide your city, state, phone number, and ZIP code.
5. Fill out the Accounting/Mailing Address section. This address should be different from your physical address if applicable. Ensure all fields are completed accurately.
6. If you have a secondary address, input it in the designated section including city, state, phone number, and ZIP code.
7. Select the appropriate type of change by checking the box that applies to your situation. If additional explanation is needed, use the Comments field.
8. Provide your Tax Identification Number (TIN) and the name exactly as reported to the IRS.
9. Sign and date the form. Your signature is mandatory for the processing of changes.
10. Finally, save the changes, then download, print, or share the completed form as needed. Ensure that you mail or fax it to the Texas Medicaid & Healthcare Partnership.

Complete your updates by filling out the Provider-Information-Change-Form online today.