Get Tx Medicaid Provider Enrollment Application 2015-2025
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How to fill out the TX Medicaid Provider Enrollment Application online
This guide is designed to assist healthcare professionals seeking to enroll as providers in the Texas Medicaid program. Completing the TX Medicaid Provider Enrollment Application thoroughly ensures a smooth enrollment process.
Follow the steps to successfully complete your application.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Fill out the ‘Provider of Service Information’ section. Include your name, type of provider, and any applicable specialty or taxonomy codes.
- Complete the ‘Disclosure of Ownership and Control Interest Statement.’ Ensure all ownership interests are accurately disclosed.
- If applicable, complete the 'Principal Information Form (PIF-2)' for each principal with an ownership interest of 5% or more in your organization.
- Fill out the ‘Provider Information Form (PIF-1)’ with specific details about your practice, including addresses and contact information.
- Review and sign the ‘HHSC Medicaid Provider Agreement,’ confirming your understanding of the requirements and responsibilities.
- Complete any additional required forms, such as the IRS W-9 Form or any relevant appendices specific to your practice type.
- To finalize your application, ensure all sections are completed, all required forms are signed, and the necessary documents are attached.
- Submit your application, including any required fees, to the Texas Medicaid & Healthcare Partnership, either by mail or electronically as applicable.
- Make sure to save any changes and consider keeping a copy of the completed application for your records.
Start your application process online today to join the Texas Medicaid provider network.
For questions regarding the TX Medicaid Provider Enrollment Application, you can reach the Texas Medicaid provider enrollment team at their dedicated phone number: 1-800-925-9126. They are available to assist you with any inquiries you may have about the enrollment process. It's a good idea to have your questions ready, so you receive the most helpful information during your call. Furthermore, utilizing resources like US Legal Forms can help you navigate the enrollment process more smoothly.
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