Get Tx Medicare Provider Enrollment Application 2012-2025
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How to fill out the TX Medicare Provider Enrollment Application online
Filling out the TX Medicare Provider Enrollment Application online can seem daunting, but this guide is here to simplify the process for you. Whether you are a new provider or need to update your information, this comprehensive step-by-step guide will walk you through each section of the application.
Follow the steps to complete the TX Medicare Provider Enrollment Application.
- Click ‘Get Form’ button to obtain the TX Medicare Provider Enrollment Application and open it in an editor.
- Begin by entering your provider type. This may include designations such as 'Individual', 'Facility', 'Group', or 'Performing Provider'. Each choice has specific instructions applicable to that category.
- In Section A, provide the Provider of Service Information. List all existing Texas Provider Identifiers (TPIs), your National Provider Identifier (NPI), and Primary Taxonomy Code. Include your business contact information, including phone number and email.
- Indicate whether you want to be a limited provider and input your Social Security Number if you are enrolling as an individual. Ensure all licensing numbers required for your provider type are completed.
- Section B requires you to fill out information regarding owners, partners, officers, directors, and principals of your practice. Provide the necessary details, ensuring total ownership equals 100%.
- If enrolling as a group practice in Section C, provide group information and names of the performing providers you are adding. Include their respective TPIs, national identification numbers, and any other necessary details.
- Complete all required forms such as the Texas Medicaid Identification Form, IRS W-9 Form, and any necessary disclosure documents specified for your provider type.
- Once you have filled out all relevant sections and forms, review everything carefully to ensure accuracy. Original signatures will be required in certain cases, such as the HHSC Medicaid Provider Agreement.
- Keep a copy of all submitted documents for your records. This is important in case of future inquiries or if any issues arise during the enrollment process.
- Mail your completed application and all required documents to the Texas Medicaid & Healthcare Partnership at the designated address.
Complete the TX Medicare Provider Enrollment Application online today to ensure you can begin providing services without delay.
The CMS Form 855R is filled out by individuals who are authorized to reassign their benefits to another provider or group practice. This typically includes physicians and non-physician practitioners who wish to designate a group or organization to receive payment on their behalf. If you're working on your TX Medicare Provider Enrollment Application, make sure to complete the 855R if necessary for your payment arrangements.
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