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Get TX TMHP HHSC Medicaid Provider Agreement (F00110) 2013-2021

Ers MUST enter the physical address where the services are rendered to clients. If the accounting, corporate, or mailing address is entered in this physical address field, the application may be denied. Number Street Suite City State ZIP Suite City State ZIP Accounting/billing address: (if applicable) Number Street As a condition for participation as a provider under the Texas Medical Assistance Program (Medicaid), the provider (Provider) agrees to comply with all terms and condition.

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