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Get TX Provider Information Change Form 2012

Vice and the CSHCN Services Program, changes to the accounting or mailing address require a copy of the W-9 form. • For Texas Medicaid fee-for-service, a change in ZIP Code requires copy of the Medicare letter for Ambulatory Surgical Centers. Federal Tax Identification Number (TIN) • Federal TIN changes for individual practitioner provider numbers can only be made by the individual to whom the number is assigned. • Performing providers cannot change the Federal TIN. Provider Demographic.

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