Get Texas Individual Allied Health Professional Application ...

Filling out the Texas Individual Allied Health Professional Application is an essential step for individuals in allied health fields seeking to provide services in Texas. This guide is designed to assist users in completing the application accurately and efficiently in an online environment.

Follow the steps to complete your application efficiently.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide your personal identification information, including last name, first name, middle initial, date of birth, social security number, gender, Texas state license number, DEA number, Medicaid/TPI number, DPS number, Medicare number, and NPI number.
3. Indicate your email address and voluntarily note your race/ethnic group if applicable. This information supports diversity goals.
4. Fill out your provider specialty information, including participation preference, age range of patients, and principal fields of specialization. Clearly marked (1) for primary and (2) for secondary specialties.
5. Complete the primary office/service address, including name, street address, city, county, state, zip code, and phone number. Specify if the provider bills from this address and if it meets ADA accessibility requirements.
6. Provide billing information, including the name (physician, group, or IPA), street address, city, state, zip, phone, and federal tax ID number (TIN).
7. If applicable, complete the secondary office/service address following the same pattern as the primary office.
8. Fill out your medical/professional education details, including the name of the medical school, city, degree earned, and date of graduation.
9. Provide information regarding residencies, fellowships, and internships, including institution names, cities, types of training, specialties, and dates.
10. Indicate board certification status, including the name of the issuing board, certification number, and attach a copy of the board certificate if applicable.
11. Complete licensing information, including expiration dates and license numbers for all states where applicable. Ensure copies of all current licenses are attached.
12. Answer the credentialing questions truthfully, providing details where applicable if any answers are 'yes'.
13. Sign and date the application, and ensure that all enclosures listed are attached.
14. Once all sections are complete, review your application for accuracy, and then save changes, download, print, or share the form as necessary.

Submit your completed Texas Individual Allied Health Professional Application online today to advance your professional journey.