Get Tx Amerihealth Caritas Provider Data Intake Form 2021-2025

This guide provides clear and concise instructions for completing the TX AmeriHealth Caritas Provider Data Intake Form online. Following these steps will ensure a smooth and efficient process for submitting essential information.

Follow the steps to fill out the form correctly.

1. Press the 'Get Form' button to access the document and open it in your preferred digital environment.
2. Begin with Section 1, where you will enter your entity name as it appears on your W9. You will also need to provide the IPA name, if applicable, and categorize your service type by selecting options such as PCP and various product types including CHIP and STAR.
3. Fill in the Name Doing Business As (if any) and the Billing Type, ensuring to provide the correct W-9 TIN/EIN number.
4. Continue through Section 1 by filling out the primary contact information, including their name, email, phone number, and address details.
5. Move to Section 2, where you will document all location details, including group or facility name, address, and contact information for each practice location. Make sure to include the respective NPI or Atypical ID and operating regions.
6. In Section 3, indicate ADA compliance for each location by marking the applicable options. Ensure that each location is specified correctly.
7. Proceed to Section 4 and select which services are provided at each location along with the age ranges served. You can also list any unlisted services and include specific ages and locations.
8. Finally, complete Section 5 by providing information on practitioners, ensuring to include their respective practice location numbers. List their names, specialties, and additional details such as accepting new patients and language proficiency.
9. Once all sections are completed, review your entries for accuracy. You can then save your changes, download, print, or share the form as needed.

Complete your TX AmeriHealth Caritas Provider Data Intake Form online today for seamless documentation.