Get Tx Provider Information Change Form 2016-2025

This guide provides essential steps for completing the TX Provider Information Change Form online. By following these instructions, you can efficiently update your provider enrollment information.

Follow the steps to complete your form accurately.

1. Click the ‘Get Form’ button to access the TX Provider Information Change Form and open it in your preferred editing tool.
2. Begin by entering the required date in the appropriate field. Ensure that you use the correct format (MM/DD/YYYY).
3. Fill in your nine-digit Texas Provider Identifier (TPI) in the designated space, followed by the provider name and National Provider Identifier (NPI).
4. Specify your primary taxonomy code and, if applicable, your atypical provider identifier (API). Include the benefit code if needed.
5. List any additional TPIs associated with the same provider information. Provide each TPI in a separate line under the 'List any additional TPIs' section.
6. Complete the physical address section without using a P.O. Box. This includes your street address, city, county, state, zip code, and contact details.
7. If you're updating the accounting/mailing address, provide the new street address, city, state, zip code, and include a copy of the W-9 Form with this application.
8. Complete the secondary address section if applicable, filling in the street address, city, state, zip code, and contact information.
9. Indicate the type of change you are reporting by checking the relevant boxes, such as changes in physical address, billing address, or provider status.
10. In the comments section, provide any additional details required for your changes, especially for significant modifications.
11. Input your federal tax identification number and the exact name as reported to the IRS. Note the effective date for these changes.
12. Specify languages spoken, office hours, patient age range, and whether you are accepting new clients. Complete additional services and limitations if applicable.
13. Ensure you sign and date the form. This is mandatory for processing your changes.
14. After reviewing your completed form for accuracy, you can save the changes, download the document, print it, or share it as needed.

Start completing the TX Provider Information Change Form online today to ensure your provider information is up-to-date.