Medicare Provider Application – Fill Out and Use This PDF

Rev. XXXVI

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Enrollment Application Instructions

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Instructions

Application

Certain providers are required to submit the application fee. his application cannot be

Payment Form

processed if the application fee is required and is not submitted with the application. For more

information, refer to “Provider Types Required to Pay an Application Fee” available on the

TMHP website at www.tmhp.com.

Medicare

REQUIRED: Medicare enrollment is a prerequisite for Medicaid enrollment if you render

Enrollment

services for clients who are eligible for Medicare. If you have a Medicare number that pertains

Information

to this enrollment, you must supply the number to TMHP. If you do not have a Medicare

number and are eligible for a Medicare Waiver Request, check the box for the waiver request

that matches your situation (see page xxv).

his information is required. Your enrollment in Texas Medicaid may be delayed if this

section of the application is not completed at the time of submission.

Type of

Choose the appropriate box to indicate if this is a new enrollment for a new provider, new

Enrollment:

provider type, new practice location, etc. or if this enrollment is in response to a

re-enrollment letter.

Requesting

Choose one as deined below:

Enrollment as:

Individual enrollment. his type of enrollment applies to an individual health-care

professional who is licensed or certiied in Texas, and who is seeking enrollment under the

name, and social security or tax identiication number of the individual. An individual may

also enroll as an employee, using the tax identiication number of the employer. Certain

provider types must enroll as individuals, including dieticians, licensed vocational nurses

(LVN), occupational therapists, and speech therapists.

Group enrollment. his type of enrollment applies to health-care items or services provided

under the auspices of a legal entity, such as a partnership, corporation, limited liability

company, or professional association, and the individuals providing health-care items or

services are required to be certiied or licensed in Texas. he enrollment is under the name and

tax identiication number of the legal entity. For any group enrollment application, there must

also be at least one enrolling performing provider.

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Requesting

Performing Provider enrollment. his type of enrollment applies to an individual health-care

Enrollment as:

professional who is licensed or certiied in Texas, and who is seeking enrollment under a group.

(cont.)

he enrollment is under the tax identiication number of the group, and payment is made

to the group. If a health-care professional is required to enroll as an individual, as explained

above, but the person is an employee and payment is to be made to the employer, the health-

care professional does not enroll as a performing provider. Instead, the health-care professional

enrolls as an individual provider under the tax identiication number of their employer.

Facility enrollment. his type of enrollment applies to situations in which licensure or

certiication applies to the entity. Although individuals working for or with the entity may be

licensed or certiied in their individual capacity, the enrollment is based on the licensure or

certiication of the entity. For this reason, facility enrollment does not require enrollment of

performing providers.

List NPI

Enter your National Provider Identiier (NPI) in this box. An NPI is not required for Financial

Management Services Agency (FMSA), Milk Donor Bank, Personal Assistance Services, and

Service Responsibility Option (SRO) providers.

Additional

Upon completion of this application, you will automatically be enrolled in the CSHCN Services

Enrollment

Program unless you opt out of CSHCN Services Program enrollment. Check the box if you

are opting out of CSHCN Services Program enrollment. If you check this box, you will only be

considered for enrollment in Texas Medicaid.

Note: If you do not check this box indicating that you would like to be considered for enrollment

in the CSHCN Services Program, also complete the following forms that are available for

download at www.tmhp.com:

CSHCN Services Program Identiication Form

Provider Agreement with the Department of State Health Services (DSHS) for

Participation in the Children with Special Health Care Needs (CSHCN) Services

Program

Required Information for Customized Durable Medical Equipment (DME) Providers

(as applicable)

Required Information for Enrollment as a CSHCN Services Program Dental

Orthodontia Provider (as applicable)

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Enrollment Application Instructions

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Instructions

Traditional

Birthing Center. To enroll in Texas Medicaid, a birthing center must be licensed by DSHS.

Services

Texas Medicaid only reimburses birthing center services that provide a level of service equal to

the professional skills of a physician, certiied nurse-midwife (CNM), or licensed midwife (LM)

who acts as the birth attendant. A birthing center is deined as a facility or institution where a

woman is scheduled to give birth following an uncomplicated (low-risk) pregnancy. his term

does not include a hospital, ambulatory surgical center, nursing facility, or residence of the

woman giving birth.

You must attach a copy of your license.

Traditional

Catheterization Lab. To enroll in Texas Medicaid, a catheterization lab must be Medicare-

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certiied.

Traditional

Certiied Registered Nurse Anesthetist (CRNA). To enroll in Texas Medicaid, a CRNA

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must be a registered nurse approved as an advanced practice nurse by the state in which they

practice and be currently certiied by either the Council on Certiication of Nurse Anesthetists

or the Council on Recertiication of Nurse Anesthetists. Medicare enrollment is a prerequisite

for enrollment as a Medicaid provider. CRNAs can enroll as an individual, group or as a

performing provider into a clinic/group practice. If enrolling into a Medicare enrolled clinic/

group practice, Medicare enrollment is required.

You must attach a copy of your CRNA certiication or re–certiication card.

Traditional

Certiied Nurse Midwife (CNM). To enroll in Texas Medicaid, a CNM must be a licensed

Services

registered nurse who is recognized by the Texas Board of Nursing as an advanced practice

nurse in nurse-midwifery and certiied by the American College of Nurse-Midwives. Medicare

enrollment is a prerequisite for enrollment as a Medicaid provider.

CNMs must complete the Physician Letter of Agreement form for Certiied Nurse Midwife

(CNM) and Licensed Midwife (LM) Providers and submit the agreement with this enrollment

application.

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Chemical Dependency Treatment Facility. Chemical dependency treatment facilities licensed

Services

by DSHS are eligible to enroll in Texas Medicaid. Chemical dependency treatment facility

services are those facility services determined by a qualiied credentialed professional, as

deined by the DSHS Chemical Dependency Treatment Facility Licensure Standards, to be

reasonable and necessary for the care of clients of any age.

You must attach a copy of your license.

Traditional

Chiropractor. To enroll in Texas Medicaid, a doctor of chiropractic (DC) medicine must

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be licensed by the Texas Board of Chiropractic Examiners and enrolled as a Medicare

provider. Chiropractors can enroll as an individual, group or as a performing provider into

a clinic/group practice. If enrolling into a Medicare enrolled clinic/group practice, Medicare

enrollment is required.

Traditional

Clinic/Group Practice. Physicians and behavioral health providers can enroll in Texas

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Medicaid as a clinic/group practice. All providers enrolled in the clinic/group practice must

be actively enrolled in Medicare and must enroll in Texas Medicaid as part of the clinic/group

practice. All providers must be licensed as Physicians by the Texas Medical Board or by the

appropriate state board where services are rendered.

Traditional

Community Mental Health Center – To enroll in Texas Medicaid, the provider must be

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actively enrolled in Medicare.

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Comprehensive Health Center (CHC). To enroll in Texas Medicaid to provide medical

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services, physicians (MD and DO) and doctors (DMD, DDS, OD, DPM, and DC) must be

licensed by the licensing authority of their profession to practice in the state where the service is

performed at the time services are provided. All physicians except pediatricians and physicians

doing only THSteps medical screens must be enrolled in Medicare before Medicaid enrollment.

Providers must submit a Medicare Waiver Request if their type of practice and service may

never be billed to Medicare.

Traditional

Comprehensive Outpatient Rehab Facility (CORF). To enroll in Texas Medicaid, a CORF

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must be Medicare-certiied. CORFs are public or private institutions primarily engaged

in providing, under medical direction, diagnostic, therapeutic, and restorative services to

outpatients, and are required to meet speciied conditions of participation.

Traditional

Dentist/Doctor of Dentistry as a Limited Physician. Dentists can enroll as traditional

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Medicaid providers to be reimbursed for medically necessary dental services, and as THSteps

dental providers to be reimbursed for preventive dental care for THSteps dental clients.

To enroll as a Doctor of Dentistry Practicing as a Limited Physician, a dentist must be currently

licensed by the TSBDE or currently be licensed in the state where the service was performed

at that time, have a Medicare provider identiication number before applying for and receiving

a Medicaid provider identiier and enroll as a Medicaid provider with a limited physician

provider identiier using the Traditional Medicaid Provider Enrollment Application.

Dentists must complete an enrollment application for each separate practice location and will

receive a unique nine-digit Medicaid provider identiication number for each practice location.

Dentists can enroll as individuals, dentist groups, or performing providers into a clinic/group

practice. he owner of the group must be a licensed dentist.

Note: he Texas Medicaid Provider Enrollment Application is required to enroll in Texas

Medicaid as a Doctor of Dentistry as a Limited Physician. To enroll in Texas Medicaid as a

THSteps dental provider, complete and submit the Texas Health Steps (THSteps) Dental Provider

Enrollment Application.

Traditional

Durable Medical Equipment (DME). A provider supplying medical equipment or appliances

Services

that are manufactured to withstand repeated use, ordered by a physician for use in the home,

and required to correct or ameliorate a client’s disability, condition, or illness. hese providers

must be Medicare-certiied as a DME/medical supplier. Providers of customized, non-basic

medical equipment, expendable medical supplies, and orthotic or prosthetic devices are also

enrolled as a DME provider. Prescriptions, insulin, and insulin syringes are covered through

the Medicaid Vendor Drug Program. Refer to the Pharmacy section for more information on

pharmacies enrolled as Comprehensive Care Program (CCP) providers.

DME providers must purchase a surety bond as a condition of enrollment in Texas Medicaid.

he State of Texas Medicaid Provider Surety Bond Form must be submitted with this

application.

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Instructions

Traditional

Family Planning Agency. Family planning services are preventive health, medical,

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counseling, and educational services that assist individuals in managing their fertility and

achieving optimal reproductive and general health. To enroll in Texas Medicaid, family

planning agencies must ensure that all services are furnished by, prescribed by, or provided

under the direction of a licensed physician and have a medical director who is a physician

currently licensed to practice medicine in Texas. Agencies must have an established record of

performance in the provision of both medical and educational/counseling family planning

services as veriied through client records, established clinic hours, and clinic site locations;

provide family planning services in accordance with DSHS standards of client care for family

planning agencies; and be approved for family planning services by the DSHS Family Planning

Program. Physicians who wish to provide Medicaid Obstetric and Gynecologic (OB-GYN)

services are allowed to bypass Medicare enrollment and obtain a Medicaid-only TPI for

OB-GYN services regardless of provider specialty. Similarly, federally qualiied health centers

do not need to apply for a separate physician or agency number. Family planning services are

payable under the existing FQHC TPI using family planning procedure codes.

Traditional

Federally Qualiied Health Center/Federally Qualiied Satellite/Federally Qualiied Look-

Services

Alike. To enroll in Texas Medicaid, a Federally Qualiied Health Center (FQHC) must be

receiving a grant under Section 329, 330, or 340 of the Public Health Service Act or designated

by the U.S. Department of Health and Human Services to have met the requirements to

receive this grant. FQHCs and their satellites are required to enroll in Medicare to be eligible

for Medicaid enrollment. FQHC “look-alikes” are not required to enroll in Medicare but may

elect to do so to receive reimbursement for crossovers. A copy of the Public Health Service

issued notice of grant award relecting the project period and the current budget period

must be submitted with the enrollment application. A current notice of grant award must be

submitted to the TMHP Provider Enrollment Department annually. Centers are required to

notify TMHP of all satellite centers that are ailiated with the parent FQHC and their actual

physical addresses. All FQHC satellite centers billing Medicaid for FQHC services must also

be approved by the Public Health Service. For accounting purposes, centers may elect to enroll

the Public Health Service–approved satellites using an Federally Qualiied Satellite (FQS)

TPI that ties back to the parent FQHC TPI and Federal Tax ID. his procedure allows for the

parent FQHC to have one provider agreement as well as one cost report combining all costs

from all approved satellites and the parent FQHC. If an approved satellite chooses to bill Texas

Medicaid directly, the center must have a separate TPI from the parent FQHC and will be

required to ile a separate cost report.

You must attach a copy of your grant award and the Federally Qualiied Health Center

Ailiation Aidavit. he form may be downloaded from the TMHP website at

www.tmhp.com.

Traditional

Freestanding Psychiatric Facility. To be eligible to participate in CCP, a psychiatric hospital/

Services

facility must be accredited by the Joint Commission, have a valid provider agreement with

HHSC, and have completed the TMHP enrollment process. Facilities certiied by Medicare

must also meet the Joint Commission accreditation requirements. Freestanding psychiatric

hospitals enrolled in Medicare may also receive payment for Medicare deductible and

coinsurance amounts with the exception of clients ages 21-64.

Traditional

Freestanding Rehabilitation Facility. To be eligible to participate in CCP, a freestanding

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rehabilitation hospital must be certiied by Medicare, have a valid Provider Agreement with

HHSC, and have completed the TMHP enrollment process. Texas Medicaid enrolls and

reimburses freestanding rehabilitation hospitals for CCP services and Medicare deductible/

coinsurance. he information in this section is applicable to CCP services only.

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Instructions

Traditional

Genetics. Only full-service genetic providers may enroll in Texas Medicaid. Before enrolling,

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the provider must contract with DSHS for the provision of genetic services. Basic contract

requirements are as follows. 1) he provider’s medical director must be a clinical geneticist

(MD or DO) who is board eligible/certiied by the American Board of Medical Geneticists

(ABMG). he physician must oversee the delivery and content of all medical services. 2)

he provider must use a team of professionals to provide genetic evaluative, diagnostic, and

counseling services. he team rendering the services must consist of at least the following

professional staf. 3) he clinical geneticist (MD or DO) and at least one of the following:

nurse, genetic associate, social worker, medical geneticist, or genetic counselor. Administrative

personnel and support staf may also be involved. Additionally, each genetic professional

providing clinical services must obtain a performing TPI from TMHP. For more contracting

information, contact: DSHS Genetic Screening and Case Management Division, 1100 West

49th Street, Austin TX 78756-3199, 512-458-7111 X2193.

Traditional

HCSSA. Home and Community Support Services Agency (HCSSA). An entity licensed

Services

by DADS that provides home care, hospice, or personal assistance services for pay or

other consideration in a client’s residence, an independent living environment, or another

appropriate location.

Refer to the Home Health section of this instruction table for additional information about

HCSSA enrollment for home health agencies.

Traditional

Hearing Aid. To enroll in Texas Medicaid, hearing aid itters and dispensers must be licensed

Services

by the licensing board of their profession to practice in the state where the services are

performed at the time the services are provided. Audiologists and physicians who provide

itting and dispensing services should choose their respective provider type.

Traditional

Home Health. Home health services (e.g., intermittent skilled nursing, physical therapy,

Services

occupational therapy and home health aide) are provided under Texas Medicaid as Title XIX

services. To enroll, a provider must be a licensed HCSSA that is also Medicare certiied. hese

facilities will have the Licensed and Certiied Home Health (LCHH) category listed on the

DADS issued license. Home health providers may render traditional Title XIX Medicaid home

health services, telemonitoring services, and CCP services.

Licensed Home Health-CCP. Licensed Home and Community Support Services Agencies

(HCSSA) that are not Medicare certiied, but have the licensed home health category on their

DADS issued license may provide only Private Duty Nursing, CCP therapy to children (0-20),

telemonitoring services, or Personal Care Services (PCS) under Texas Medicaid Comprehensive

Care Program. HCSSAs that also wish to provide Title XIX, Medicaid home health services

must also be Medicare certiied.

Note: Home health providers with a category of service of hospice are not enrolled in Texas

Medicaid.

Traditional

Hospital – In State. To be eligible to participate in Texas Medicaid, a hospital must be certiied

Services

by Medicare, have a valid provider agreement with HHSC, and have completed the TMHP

enrollment process.

Traditional

Hospital Ambulatory Surgical Center (HASC). Hospitals certiied and enrolled in Texas

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Medicaid are assigned a nine-character TPI (HASC) exclusively for billing day surgeries.

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Traditional

Hospital – Military. To enroll in Texas Medicaid, a military hospital must be certiied by

Services

Medicare, have a valid provider agreement with HHSC, and have completed the TMHP

enrollment process. Veteran’s Administration (VA) hospitals are eligible to receive Texas

Medicaid payment only on claims that have crossed over from Medicare.

Traditional

Hospital – Out of State. To be eligible to participate in Texas Medicaid, a hospital must be

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certiied by Medicare, have a valid provider agreement with HHSC, and have completed the

TMHP enrollment process.

Traditional

Hyperalimentation. To enroll in Texas Medicaid, providers of in-home total parental

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parenteral nutrition must be enrolled in Medicare (Palmetto) as in-home total parental

hyperalimentation supplier providers.

Traditional

Independent Diagnostic Testing Facility (IDTF). To enroll in Texas Medicaid, an IDTF

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provider must be actively enrolled in Medicare.

Traditional

Independent Laboratory (No Physician involvement/Physician involvement). To enroll

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in Texas Medicaid, the independent (freestanding) laboratory must: 1) be independent from

a physician’s oice or hospital; 2) meet staf, equipment, and testing capability standards for

certiication by HHSC; and 3) have Medicare certiication.

Traditional

Licensed Marriage Family herapist (LMFT). To enroll in the Texas Medicaid Program,

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whether as an individual or as part of a group, a licensed marriage and family therapist

(LMFT) must be licensed by the Texas State Board of Examiners of Licensed Marriage and

Family herapists. LMFTs are covered as Medicaid-only providers. herefore, enrollment in

Medicare is not a requirement. LMFTs can enroll as part of a clinic/group practice whether or

not they are enrolled in Medicare. Providers that hold a temporary license are not eligible to

enroll in the Texas Medicaid Program.

Traditional

Licensed Midwife (LM). To enroll in Texas Medicaid, an LM must be licensed and approved

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by the Texas Midwifery Board under Chapter 203 of the Occupations Code and 22 TAC

Chapter 831 (relating to Midwifery). Per the Afordable Care Act, Section 2301, LMs are able

to perform certain professional services in birthing centers, given they are licensed birthing

attendants as recognized by Texas. LMs are required to retain a referring/consulting physician

as a condition of enrollment. LMs can enroll as an individual, group, or performing provider

into a clinic/group practice. LMs are not recognized by Medicare and are not required to enroll

in Medicare as a prerequisite for Medicaid enrollment.

LMs must complete the Physician Letter of Agreement form for Certiied Nurse Midwife

(CNM) and Licensed Midwife (LM) Providers and submit the agreement with this enrollment

application.

Traditional

Licensed Professional Counselor (LPC). To enroll in the Texas Medicaid Program,

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independently or as a group of practicing licensed professional counselors (LPCs), you must

be licensed by the Texas State Board of Examiners of Professional Counselors. LPCs are

covered as Medicaid-only providers; therefore, enrollment in Medicare is not a requirement

for enrollment in Medicaid. Practitioners holding a temporary license are not eligible to enroll

in Medicaid. LPCs can enroll as an individual, group or as a performing provider into a clinic/

group practice. he Provider Agreement, Provider Information Form (PIF-1) and, Principal

Information Form (PIF-2) must be complete for the group and each performing provider

enrolling into the group.

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Instructions

Traditional

Maternity Service Clinic (MSC). To enroll in Texas Medicaid, maternity service clinics (MSC)

Services

must ensure that the physician prescribing the services is employed by or has a contractual

agreement/formal arrangement with the clinic to assume professional responsibility for the

services provided to clinic patients. To meet this requirement a physician must see the patient

at least once, prescribe the type of care provided, and if the services are not limited by the

prescription, periodically review the need for continued care. Medicare certiication is not a

prerequisite for MSC enrollment. An MSC must: 1) be a facility that is not an administrative,

organizational, or inancial part of a hospital; 2) be organized and operated to provide

maternity services to outpatients; 3) comply with all applicable federal, state, and local laws

and regulations; 4) an MSC wanting to bill and receive reimbursement for case management

services to high-risk pregnant adolescents, women, and infants must meet the criteria speciied

in the Case Management for Children and Pregnant Women section.

Traditional

Nurse Practitioner/Clinical Nurse Specialist (NP/CNS). To enroll in Texas Medicaid, a Nurse

Services

Practitioner (NP), or Clinical Nurse Specialist (CNS) must be licensed as a registered nurse and

recognized as an Advanced Practice Registered Nurse (APRN) by the Texas Board of Nursing

(TBON). An NP or a CNS can enroll as an individual provider, or a performing provider of a

clinic/group practice. If an NP or a CNS is enrolling as a performing provider in a Medicare-

enrolled clinic/group practice, the NP or CNS must also be enrolled in Medicare. Providers

must submit a Medicare Waiver Request if their type of practice and service may never be

billed to Medicare. Under the multi-state licensure compact, an APRN may be licensed in

another state but must also be certiied as an APRN by the TBON.

Traditional

Occupational herapist (OT). To enroll in Texas Medicaid, the provider must be licensed

Services

as an Occupational herapist by the Executive Council of Physical herapy & Occupational

herapy Examiners or by the appropriate state board where services are rendered. he provider

must be actively enrolled in Medicare as an occupational therapist.

Occupational therapists are also eligible to enroll in CCP. Refer to the Occupational herapist-

CCP section of this instructions table for additional information.

Traditional

Optician. To enroll in the Texas Medicaid Program, doctors of optometry must be licensed by

Services

the licensing board of their profession to practice in the state where the service was performed,

at the time the service was performed, and be enrolled as Medicare Providers. Opticians

can enroll as an individual, group or as a performing provider into a clinic/group practice. If

enrolling into a Medicare enrolled clinic/group practice, Medicare enrollment is required..

Traditional

Optometrist (OD). To enroll in the Texas Medicaid Program, doctors of optometry must be

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licensed by the licensing board of their profession to practice in the state where the service

was performed, at the time the service was performed, and be enrolled as Medicare Providers.

Optometrists can enroll as an individual, group or as a performing provider into a clinic/group

practice. If enrolling into a Medicare enrolled clinic/group practice, Medicare enrollment is

required.

Traditional

Orthotist. Orthotists must be enrolled in Medicare and licensed by the Texas Board of

Services

Orthotics and Prosthetics as a licensed orthotist (LO) or licensed prosthetist/orthotist (LPO)

to measure, design, fabricate, assemble, it, adjust, or service an orthosis for the correction or

alleviation of a neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity.

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Instructions

Traditional

Outpatient Rehabilitation Facility (ORF). To enroll in Texas Medicaid, an ORF must be

Services

Medicare-certiied. ORFs are public or private institutions primarily engaged in providing,

under medical direction, diagnostic, therapeutic, and restorative services to outpatients, and

are required to meet speciied conditions of participation.

Traditional

Personal Assistant Services/PCS. Providers that want to participate in the delivery of PCS

Services

must have one of the following Texas Department of Aging and Disability Services (DADS)

licensures:

Personal assistance services (PAS)

Licensed home health services (LHHS)

Licensed and certiied home health services (LCHHS)

Licensed Home and Community Support Services Agencies (HCSSA) that are not Medicare

certiied may provide ONLY Personal Care Services (PCS) under Texas Medicaid CCP.

Traditional

Pharmacy Group. A pharmacy is a facility used by pharmacists for the compounding and

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dispensing of medicinal preparations and other associated professional and administrative

services. A pharmacy is a facility whose primary function is to store, prepare and legally

dispense prescription drugs under the professional supervision of a licensed pharmacist. It

meets any licensing or certiication standards set forth by the jurisdiction where it is located.

Pharmacies must complete an application as a “group” if interested in providing Medicaid

clients only vaccines. As a “group” applicant, at least one performing provider application

must be submitted as a pharmacist. Pharmacies must be certiied by Medicare. Pharmacies

must complete the application as a “facility” if interested in providing DME and supplies to all

Medicaid clients. Each pharmacy must be certiied by Medicare.

Traditional

Pharmacist. A pharmacist is an individual licensed by the appropriate state regulatory

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agency to engage in the practice of pharmacy. he practice of pharmacy includes, but is not

limited to: assessment, interpretation, evaluation and implementation, initiation, monitoring

or modiication of medication and or medical orders; the compounding or dispensing of

medication and or medical orders; participation in drug and device procurement, storage,

and selection; drug administration; drug regimen reviews; drug or drug-related research;

provision of patient education and the provision of those acts or services necessary to provide

medication therapy management services in all areas of patient care. Pharmacists must

complete an application as an “individual” or “performing provider” under a pharmacy

“group” if interested in providing Medicaid clients only vaccines. Pharmacists must be certiied

by Medicare and certiied to perform immunizations.

Traditional

Physical herapist (PT). To enroll in Texas Medicaid, independently practicing licensed

Services

physical therapists must be enrolled in Medicare. If you are currently enrolled with Texas

Medicaid or plan to provide regular acute care services to clients with Medicaid coverage,

enrollment in CCP is not necessary. All non-CCP physical therapy services must be billed with

your current Medicaid TPI.

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Instructions

Traditional

Physician. To enroll in Texas Medicaid in order to provide medical services, physicians (M.D.

Services

and D.O.) must:

Be licensed by the licensing authority of their profession to practice in the state where the

services are performed at the time the services are provided.

Be enrolled as a Medicare provider with the exception of pediatricians and obstetrics and

gynecology (OB-GYN) providers

Submit a Medicare Waiver Request if their type of practice and service may never be billed

to Medicare.

If enrolling into a Medicare enrolled clinic/group practice, Medicare enrollment is required.

Physicians can enroll as an individual, group, or as a performing provider into a clinic/group

practice. Otorhinolaryngologists who provide itting and dispensing services are no longer

required to submit a separate enrollment application to dispense hearing aids.

Traditional

Physician Assistant (PA). To enroll in Texas Medicaid, a PA must be licensed as a PA and

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be recognized as a PA by the Texas Physician Assistant Board. All PAs are enrolled within

the categories of practice as determined by the Texas Medicaid Board. PAs can enroll as an

individual, group, or as a performing provider into a clinic/group practice. If enrolling into a

Medicare enrolled clinic/group practice, Medicare enrollment is required.

Traditional

Physiological Lab. To enroll in Texas Medicaid, radiological and physiological laboratories

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and portable X-ray suppliers must be enrolled in Medicare. Both radiological and physiological

laboratories must be directed by a physician.

Traditional

Podiatrist. Podiatrists (DPM) must be Medicare-certiied and enrolled as Medicaid providers

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are authorized to perform procedures on the ankle or foot as approved by the Texas Legislature

under their licensure as a DPM when such procedures would also be reimbursable to a

physician (MD or DO) under the Texas Medicaid Program. Podiatrists can enroll as an

individual, group or as a performing provider into a clinic/group practice. If enrolling into a

Medicare enrolled clinic/group practice, Medicare enrollment is required.

Traditional

Portable X-Ray. To enroll in Texas Medicaid, radiological and physiological laboratories

Services

and portable X-ray suppliers must be enrolled in Medicare. A physician must direct both

radiological and physiological laboratories.

Traditional

Prosthetist. Prosthetists must be enrolled in Medicare and licensed by the Texas Board of

Services

Orthotics and Prosthetics as a prosthetist (LP) or prosthetist/orthotist (LPO) to measure,

design, fabricate, assemble, it, adjust, or service a prosthesis.

Traditional

Prosthetist/Orthotist – To enroll as a prosthetist/orthotist, you must be licensed as both. Refer

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to the Prosthetist and Orthotist sections of these instructions for additional information.

Traditional

Psychologist. To enroll in the Texas Medicaid Program, an independently practicing

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psychologist must be licensed by the Texas State Board of Examiners of Psychologists and

be enrolled as a Medicare provider. Psychologists can enroll as an individual, group or as a

performing provider into a clinic/group practice. If enrolling into a Medicare enrolled clinic/

group practice, Medicare enrollment is required.

A copy of the psychologist’s license that is not due to expire within 30 days must be submitted

with this application.

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Item

Instructions

Traditional

Qualiied Rehabilitation Professional (QRP). A person who meets one or more of the

Services

following criteria: a) Holds a certiication as an assistive technology professional or a

rehabilitation engineering technologist issued by, and in good standing with, the Rehabilitation

Engineering and Assistive Technology Society of North America (RESNA); b) Holds a

certiication as a seating and mobility specialist issued by, and in good standing with, RESNA;

and/or c) Holds a certiication as a certiied rehabilitation technology supplier issued by, and in

good standing with, the National Registry of Rehabilitation Technology Suppliers (NRRTS).

A copy of the NRRTS/RESNA certiication must be submitted with this application.

Traditional

Radiation Treatment Center. To enroll in Texas Medicaid, Radiation Treatment Centers must

Services

be Medicare-certiied and certiied by HHSC Bureau of Radiation Control.

Traditional

Radiological Lab. To enroll in Texas Medicaid, radiological and physiological laboratories

Services

and portable X-ray suppliers must be enrolled in Medicare. A physician must direct both

radiological and physiological laboratories.

Traditional

Renal Dialysis Facility. To enroll in Texas Medicaid, a renal dialysis facility must be Medicare-

Services

certiied in the state that it is located to provide services. Facilities must also adhere to the

appropriate rules, licensing, and regulations of the state where they operate.

Traditional

Respiratory Care Practitioner (CRCP). To enroll in Texas Medicaid, a certiied respiratory

Services

care practitioner (CRCP) must be certiied by HHSC to practice under Texas Civil Statutes,

Article 4512L. As of January 1, 1988, the National Board for Respiratory Care Exam must

be passed to be certiied by HHSC. Medicare certiication is not a prerequisite for Medicaid

enrollment.

Traditional

Rural Health Clinic – Hospital, Freestanding. Medicare is required for enrollment as a Title

Services

XIX Rural Health Clinic (RHC).

Traditional

Skilled Nursing Facility. To enroll in Texas Medicaid, the provider must be licensed as a

Services

nursing facility by DADS or by the appropriate state board where services are rendered. he

provider must be actively enrolled in Medicare as a skilled nursing facility.

Traditional

Social Worker (LCSW). To enroll in the Texas Medicaid Program independently or as a

Services

clinic/group practice, a licensed clinical social worker (LCSW) must be licensed through the

State Board of Social Work Examiners as a LCSW and be enrolled in Medicare. Providers

must submit a Medicare Waiver Request if their type of practice and service may never be

billed to Medicare. Practitioners holding a temporary license are not eligible to enroll in

Medicaid. Social Workers can enroll as an individual, group or as a performing provider into

a clinic/group practice. If enrolling into a Medicare enrolled clinic/group practice, Medicare

enrollment is required.

Traditional

SHARS – School, Co-op, or School-Based Health Center. To enroll in Texas Medicaid,

Services

school-based health centers, including charter schools, must employ, or contract with,

individuals or entities that meet certiication and licensing requirements in accordance with

the Texas Medicaid State Plan for SHARS in order to bill and be reimbursed for program

services. (See the current Texas Medicaid Provider Procedures Manual, School Health and

Related Services.)

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Traditional

Specialized/Custom Wheeled Mobility. A provider supplying items of durable medical

Services

equipment that are powered or manual mobility systems, including seated positioning

components, powered or manual seating options, electronic drive control, specialty driving

controls, multiple adjustment frame, nonstandard optimizations, and other complex or

specialized components for clients.

Traditional

TB Clinic. To enroll in Texas Medicaid, the tuberculosis (TB) clinic must be approved by the

Services

Department of State Health Services (DSHS) Infectious Disease Control Unit Tuberculosis

Program (IDCU/TB). he TB clinic must be one of the following: a public entity operating

under a Texas Health and Human Services Commission (HHSC) tax identiication number

(TB regional clinic), a public entity operating under a non-HHSC tax identiication number

(city/county/local clinic), or a non-hospital-based entity for private providers and a provider of

TB-related clinic services.

To receive a DSHS Tuberculosis and Refugee Health Services Branch Medicaid Provider

Application, send a request to the following address: Tuberculosis Elimination Division,

ATTN: Financial Services and Medicaid Unit, 1100 West 49th Street, Austin TX 78756-3199, or

call 1-512-533-3000 for more information.

You must attach a copy of your approval letter from the state of Texas.

Traditional

Vision Medical Supplier (VMS). To enroll in Texas Medicaid, doctors of optometry must

Services

be licensed by the licensing board of their profession to practice in the state where the service

was performed, at the time the service was performed, and be enrolled as Medicare (Palmetto)

Providers.

Texas Medicaid Identiication Form – Case Management Services

Case Management

Blind Children’s Vocational Discovery & Development Program. he Texas Commission for

Services

the Blind (TCB) is eligible to enroll as a Medicaid provider of case management for blind and

visually impaired clients (BVIC) younger than age 16.

Case Management

Case Management for Children and Pregnant Women/ Targeted Case Management

Services

(PWI )/THSteps Medical Case Management Services. Enrollment for Case Management

for Children and Pregnant Women is a two-step process. Potential providers must submit

a Texas Department of State Health Services (DSHS) Case Management for Children and

Pregnant Woman application to the DSHS Health Screening and Case Management Unit.

Upon approval by DSHS potential providers must enroll as a Medicaid provider for Case

Management for Children and Pregnant Women. Ater the enrollment process is completed,

the applicant is notiied, in writing, of the provider status and TPI. he facility must enroll as

a group and enroll registered nurses and social workers as performing providers of the group.

he Provider Agreement, Provider Information Form (PIF-1) and Principal Information

Form (PIF-2) must be completed for each principal of the group and each performing provider

enrolling into the group.

You must attach a copy of your approval letter from DSHS if you are enrolling as a new group

or individual.

Note: THSteps Medical Case Management (MCM) and Targeted Case Management for High

Risk Pregnant Women and High Risk Infants (PWI) Programs are combined with the Case

Management for Children and Pregnant Women (CPW) Program.

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Item

Instructions

Case Management

Early Childhood Intervention (ECI). To participate in Texas Medicaid, an ECI provider must

Services

comply with all applicable federal, state, local laws, and regulations about the services provided.

Contractors must be certiied by the Texas ECI program and must submit a copy of the current

contract award from the Texas ECI program.

You must attach a copy of your approval letter from the Interagency Council on Early

Childhood Intervention.

Case Management

Home and Community Based Service–Adult Mental Health (HCBS-AMH). To enroll in

Services

Texas Medicaid, a HCBS-AMH provider must be approved by DSHS. HCBS-AMH providers

must enroll as a facility and are not required to enroll in Medicare.

HCBS-AMH providers must submit proof of approval and adhere to the appropriate rules,

licensing and regulations of the state in which they operate.

Case Management

Intellectual and Developmental Disability Case Management (IDD)–Local Intellectual and

Services

Developmental Disability Authority (LIDDA). To enroll in Texas Medicaid, LIDDA providers

of IDD case management must contact the Department of Aging and Disability Services

(DADS) at 1-512-438-3011 for approval. LIDDA providers are eligible to become providers of

IDD case management with the approval of DADS.

You must attach a copy of your approval letter from the state of Texas.

Case Management

Mental Health (MH) Case Management–Local Mental Health Authority (LMHA).

Services

To enroll in Texas Medicaid, LMHA providers must contact the Department of State Health

Services (DSHS) at 1-512-206-5288 to be approved. LMHA providers are eligible to become

providers of MH case management services with the approval of DSHS.

You must attach a copy of your approval letter from the state of Texas.

Case Management

MH Rehabilitative Services–LMHA. To enroll in Texas Medicaid, MH Rehabilitative

Services

Services–LMHA providers must contact DSHS at 1-512-206-5288 to be approved. LMHA

providers are eligible to become providers of MH rehabilitative services with the approval of

DSHS.

You must attach a copy of your approval letter from the state of Texas.

Case Management

MH Case Management/MH Rehabilitative Services–Non-LMHA. Non-LMHAs are private

Services

providers of both MH case management and MH rehabilitative services, but they are not

LMHAs. hey must comply with all applicable federal and local laws and all of the regulations

that are related to the services they provide. Ater receiving approval for enrollment in Texas

Medicaid, the Non-LMHA provider must be credentialed by a Texas Medicaid managed care

organization (MCO) to provide services to Texas Medicaid clients.

Note: Non-LMHA providers must register to use the Department of State Health Services (DSHS)

Clinical Management for Behavioral Health Services (CMBHS) clinical record-keeping system

before providing services to Texas Medicaid clients.

Case Management

Women, Infant, & Children (WIC) (Immunization Only). To be eligible as a qualiied

Services

provider for presumptive eligibility determinations the following federal requirements must

be met. he provider must be 1) an eligible Medicaid provider; 2) provide outpatient hospital

services, rural health clinic services, or clinic services furnished by or under the direction of

a physician without regard to whether the clinic itself is administered by a physician (includes

family planning clinics); and 3) receive funds from or participate in the WIC program.

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Item

Instructions

Case Management

Youth Empowerment Services (YES) Waiver. To enroll in Texas Medicaid, YES Waiver

Services

providers must contact DSHS at YESWaiver@dshs.state.tx.us to be approved. Upon approval

by DSHS potential providers must enroll as a Medicaid provider for YES Waiver.

You must attach a copy of your YES Waiver DSHS contract.

CCP Services

Dietitian. Independently practicing licensed dietitians may enroll in Texas Medicaid to

provide services to CCP clients. Providers of nutritional services and counseling must be

licensed by the Texas State Board of Examiners of Dietitians in accordance with the Licensed

Dietitians Act, Article 4512h.

CCP Services

Financial Management Services Agency (FMSA). To enroll in Texas Medicaid, FMSA

providers must submit their contract with the Department of Aging and Disability Services as

a Financial Management Services Agency provider.

CCP Services

Licensed Vocational Nurse (LVN). Independently enrolled licensed vocational nurses may

also enroll to provide private duty nursing (PDN) under Texas Medicaid CCP. In order to

enroll, the LVN must submit a plan of RN supervision, including the name and license number

of the RN providing the supervision.

CCP Services

Milk Donor. To enroll in Texas Medicaid, the provider must adhere to quality guidelines

consistent with the Human Milk Bank Association of Northern America.

CCP Services

Occupational herapist (OT-CCP). HHSC allows Medicaid enrollment of independently

practicing licensed occupational therapists in CCP. Licensed HCSSAs are also able to provide

occupational therapy in CCP.

CCP Services

Pharmacy. Pharmacy providers are eligible to enroll in CCP. To be enrolled in CCP, the

pharmacy must irst be enrolled in the Texas Medicaid Vendor Drug Program (VDP).

Pharmacies enrolling as CCP-only providers do not require Medicare certiication to enroll.

Only taxonomy code 336000000X is available for selection during the enrollment process.

See “Traditional Services – Pharmacy Group” for additional information about pharmacies.

CCP Services

Physical herapist (PT-CCP). he Medicare enrollment requirement is waived for therapists

providing services only to THSteps-eligible clients who are 20 years of age and younger and

who are not receiving Medicare beneits. Physical therapy services may also be provided by

a licensed HCSSA. CCP physical therapy may be provided by either a licensed and certiied

home health provider or licensed HCSSA, and physical therapy through Medicaid home health

services may be provided by a licensed and certiied HCSSA.

CCP Services

Prescribed Pediatric Extended Care Center. To enroll in the Texas Medicaid Program, a

Prescribed Pediatric Extended Care Center (PPECC) provider must be licensed by the Texas

Department of Aging and Disability Services (DADS). PPECC providers must enroll as a

facility and are not required to enroll in Medicare.

PPECC providers must submit proof of their licensure and adhere to the appropriate rules,

licensing and regulations of the state in which they operate.

CCP Services

Registered Nurse (RN). Independently enrolled registered nurses may also enroll to provide

private duty nursing under CCP.

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Item

Instructions

CCP Services

Service Responsibility Option (SRO). To enroll in the Texas Title XIX Medicaid Program,

Service Responsibility Option providers must complete the Texas Medicaid enrollment

application. Providers of personal assistance services must submit their contract with the

Department of Aging and Disability Services as a Service Responsibility Option provider.

CCP Services

Speech herapist (SLP). HHSC allows enrollment of independently practicing licensed speech-

language pathologists under the THSteps-CCP. Texas Medicaid enrolls and reimburses speech-

language pathologists for CCP services only.

Texas Medicaid Identiication Form – Other Texas Medicaid Services

Texas Health Steps

Check the box on page 1-3 if you elect not to participate as a provider for THSteps preventive

(THSteps) services

medical checkups. If you decided at a later time to participate as a provider for THSteps

(i.e., EPSDT)

preventive medical checkups, you will be required to complete and submit the THSteps

Provider Enrollment Application that is available on the TMHP website at www.tmhp.com.

By leaving this box unchecked, you may be issued a THSteps medical provider identiier in

addition to the provider identiier for your requested provider type. To enroll in the THSteps

program, a provider must be a licensed physician (MD, DO); physician assistant (PA); clinical

nurse specialist (CNS); nurse practitioner (NP); certiied nurse midwife (CNM); federally

qualiied health centers (FQHC); health-care provider of a facility (public or private) capable

of performing the required medical checkup procedures under the direction of a physician;

(such as a regional and local health department; family planning clinic; migrant health clinic;

community-based hospital and clinic; maternity clinic; rural health clinic; home health agency;

or school-based health center).

Texas Vaccines for

Check the appropriate boxes in response to the questions. Providers that provide routinely

Children Program

recommended vaccines to children who are 18 years of age and younger can apply to receive

(TVFC)

free vaccines from TVFC. he TVFC Provider Agreement is available in the forms section of

the TVFC website at www.dshs.texas.gov/immunize/tvfc/ProviderResources.shtm.

Texas Medicaid Provider Enrollment Application

A.1 - A.3 Provider

his section is for provider demographic information. Provide complete and correct

of Services

information as required.

Information

A.4 Healthy Texas

Choose the appropriate statement.

Women (HTW)

If you will be rendering services for HTW clients, you must complete and submit the Healthy

Texas Women Certiication form with this application. his form must be completed and

submitted by providers that render women’s health and family planning services to clients who

participate in the Healthy Texas Women program. An original signature is required. his form

cannot be faxed to TMHP. he form is located in Appendix A of this application.

Important: Under Texas Human Resources Code, Section 32.024(c-1), and relating program

rules in the Texas Administrative Code, the provider or the provider’s ailiated organization is

not qualiied to participate in and is ineligible to bill for services provided through the Healthy

Texas Women program if the provider or anyone in the provider’s organization performs

or promotes elective abortions, or is an ailiate of another entity that performs or promotes

elective abortions.

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Item

Instructions

B.1 - B.2

Completion and submission of this form is a condition of participation, certiication or

Disclosure of

recertiication under any of the programs established by Titles V, XVIII, XIX, and XX or as a

Ownership and

condition of approval or renewal of a contractor agreement between the disclosing entity and

Control Interest

the secretary of appropriate state agency under any of the above-titled programs, a full and

Statement

accurate disclosure of ownership and inancial interest is required. Failure to submit requested

information may result in a refusal by the appropriate State agency to enter into an agreement

or contract with any such institution in termination of existing agreements.

Note: Each creditor with a security interest in a debt that is owed by the Provider if the creditor’s

security interest is protected by at least 5% of the provider’s property must be listed in this form.

Every individual and entity on the list must complete and submit a PIF-2 form.

B.3 PIF-2

A separate copy of the Principal Information Form (PIF-2) must be completed in full for each

principal, subcontractor, and creditor of the Provider, before enrollment.

C. Group Practice

Group practice information. If this enrollment is for a group practice, please complete Section

C, and provide complete and correct information as required.

D. PIF-1

Each Provider must complete the Provider Information Form (PIF-1), before enrollment.

Important: he physical address is where health care is rendered. In the Physical Address

ield, providers MUST enter the physical address where the services are rendered to clients; the

accounting, corporate, or mailing address must NOT be entered in the physical address ield. If a

site visit is required and cannot be conducted because the physical address was not provided, the

enrollment application will be denied.

HHSC Medicaid

Complete the required information at the beginning of the form, read the agreement

Provider

information, and sign and date the agreement to indicate that you have read and agree with the

Agreement

terms of enrollment as required by the Texas HHSC.

Important: he physical address is where health care is rendered. In the Physical Address

ield, providers MUST enter the physical address where the services are rendered to clients; the

accounting, corporate, or mailing address must NOT be entered in the physical address ield. If a

site visit is required and cannot be conducted because the physical address was not provided, the

enrollment application will be denied.

IRS W–9 Form

Provide complete and correct information as required.

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Page xxvii

Application Payment Form

Rev. XXXVI

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Name of Provider Enrolling:

Group/Company or Last Name

First

Middle Initial

Public/Private entities:

Deinition — Public entities are those that are owned or operated by a city, state, county, or other

(required of all providers)

government agency or instrumentality, according to the Code of Federal Regulations, including any

agency that can do intergovernmental transfers to the State. Public agencies include those that can certify

and provide state matching funds.

Are you a private or public entity?

F Private

F Public

If you are a public entity, are you required to certify expended

F Yes

F No

funds?

Name and address of a person certifying expended funds:

Is this a freestanding facility?

F Yes

F No

Is this a hospital-based facility?

F Yes

F No

Facilities only:

Is this an ESRD facility?

F Yes

F No

If Yes, what is your composite rate?

Do you provide hearing services for children?

F Yes

F No

Hearing aid providers only:

Will you be itting and dispensing hearing aids?

F Yes

F No

Are you enrolling as a school district?

F Yes

F No

If Yes, give school six-digit T.E.A. number:

School Health and Related

Are you enrolling as a special education co-op?

F Yes

F No

If Yes, attach a list of all school districts in the co-op that will be

Services (SHARS) providers

providing SHARS services. Provide the following information for each

only:

school district:

omplete address

chool District Number

.E.A. number.

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Texas Medicaid Provider Enrollment Application

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VI.

Staing

(a)

Has there been a change in Administrator, Director of Nursing, or Medical Director within the

 Yes

 No

last year?

VII.

Ailiation

(a)

Is the provider identiied in Section I. above chain ailiated?

 Yes

 No

Name

Address

Federal Tax ID

VIII.

Capacity

(a)

Have you increased your bed capacity by 10 percent or more or by 10 beds, whichever is greater,

 Yes

 No

within the last two years? (For Hospitals only)

If Yes, give:

Year of change:

Current Beds:

Prior Beds:

IX.

Disclosure of Relationship