Pif 2 Form – Fill Out and Use This PDF

Principal Information Form (PIF-2)

Required for any person or entity that meets the definition of a “Principal” or “Subcontractor”

as defined below.

A separate copy of this Principal Information Form (PIF-2) must be completed in full for each Principal or Subcontractor of the Provider, before enrollment.

A Principal of the Provider is defined as follows:

All owners with a direct or indirect ownership or control interest of 5 percent or more.

All corporate officers and directors, all limited and non-limited partners, and all shareholders of a provider entity (including a professional corporation, professional association, or limited liability company).

All managing employees or agents who exercise operational or managerial control, or who directly or indirectly manage the conduct of day-to-day operations.

All individuals, companies, firms, corporations, employees, independent contractors, entities or associations who have been expressly granted the authority to act for or on behalf of the provider.

All individuals who are able to act on behalf of the provider because their authority is apparent.

A Subcontractor of the Provider is defined as follows:

An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or

An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies

All spaces must be completed either with the correct answer or a “NA” on the questions that do not apply to the Principal or Subcontractor.

All owners that have a 5 percent or more direct or indirect ownership interest in a provider that is assigned a high- categorical risk level must submit fingerprints for enrollment or revalidation in Texas Medicaid.

The Provider or provider’s duly authorized representative must personally review each copy of this completed form and certify to the validity and completeness of the information provided by signing the Provider Agreement.

Check person or entity:  Person  Entity If “Entity,” please complete the following information.

Company Name:

Address as shown on the W9 IRS form:

Number Street

Suite

City

State

ZIP

How is the entity organized to conduct business activities? Examples include: Sole Proprietor (Unincorporated), Professional Association, General Partnership, Limited Partnership, Limited Liability Partnership, Limited Liability Company, Corporation, Nonprofit, Governmental

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If you selected “Person” above, please complete the following information.

The following information must be completed by all Principals, Subcontractors, and Creditors. For additional names or addresses, attach pages as necessary.

Check principal or subcontractor:		 Principal	 Subcontractor
Physical Address:
Number	Street	Suite	City	State	ZIP
Accounting/Billing Address:
Number	Street	Suite	City	State	ZIP

If your accounting address is different than your physical address, indicate your relationship to the accounting address:

 Billing agent  Management company  Employer  Self  Other (explain below)

If you chose “Other,” please explain:

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Do you have one or more professional licenses, accreditations, or certifications?

 Yes		 No	If “Yes,” provide the following information.
1.	Professional Licensing or Certification Board:				Licensing State:
	License Accreditation Certification Issuer:				License Accreditation Certification Number:
	Issue Date (mm/dd/yyyy):				Expiration Date (mm/dd/yyyy):
2.	Professional Licensing or Certification Board:				Licensing State:
	License Accreditation Certification Issuer:				License Accreditation Certification Number:
	Issue Date (mm/dd/yyyy):				Expiration Date (mm/dd/yyyy):
3.	Professional Licensing or Certification Board:				Licensing State:
	License Accreditation Certification Issuer:				License Accreditation Certification Number:
	Issue Date (mm/dd/yyyy):				Expiration Date (mm/dd/yyyy):
4.	Professional Licensing or Certification Board:				Licensing State:
	License Accreditation Certification Issuer:				License Accreditation Certification Number:
	Issue Date (mm/dd/yyyy):				Expiration Date (mm/dd/yyyy):
Previous Physical address:
Number		Street		Suite	City	State	ZIP

Previous Accounting address:

Number

Street

Suite

City

State

ZIP

Your title in the provider organization for which enrollment is being sought:

Your duties to the provider organization (attach additional sheets if necessary):

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Your role in the provider organization: Examples are Accountant, Agency, Attorney, Banker, Bookkeeper, Business, Care Giver, Consultant, Contractual, Corporate Officer, Director, Doctor, Elected Official, Employee, Employer, Government Official , Individual (Contracted), Individual (Fiscal Agent), Limited Partner, Managing Employee, Medical Director, Non-Limited Partner, Nurse, Official, Owner (Direct), Owner (Indirect) Parent, Recruiter, Representative, Shareholder, Subcontractor, or Unknown: (attach additional sheets if necessary)

Effective date of your role in the provider organization (mm/dd/yyyy):

Do you have a relationship with a separate provider? (If “Yes,” explain relationship below)	 Yes  No

Explain relationship with the separate provider:

List all TPIs, provider names, and physical locations under which you have billed or in which your were a principal. Include current and previous TPIs (attach additional sheets if necessary):

List all Providers and medical entities that you have a contractual relationship with and, if known, the NPI/API and TPI of each provider or entity. (Attach additional sheets if necessary.)

1.	Name:			Social Security Number:			Date of Birth (mm/dd/yyyy):
	Physical Address:
	Number	Street		Suite	City		State	ZIP
	Federal Tax ID:		TPI:			NPI/API:
2.	Name:			Social Security Number:			Date of Birth (mm/dd/yyyy):
	Physical Address:
	Number	Street		Suite	City		State	ZIP
	Federal Tax ID:		TPI:			NPI/API:
3.	Name:			Social Security Number:			Date of Birth (mm/dd/yyyy):
	Physical Address:
	Number	Street		Suite	City		State	ZIP

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If “Yes,” fully explain the details, including date, the state where the incident occurred, the agency taking the action, and the program affected. (Attach additional sheets if necessary)

If “Yes” was answered to any of these questions, fully explain the details, including date, the state where the incident occurred, name of the board or agency, and any adverse action against your license. (Attach additional sheets if necessary)

If “Yes” was answered to any of the questions, fully explain the details including date, and the state if applicable.

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If “Yes,” fully explain the details, including date, the state and county where the conviction occurred, the cause number(s), and specifically what you were convicted of. (attach additional sheets if necessary)

 Yes  No

 Yes  No

If “Yes,” provide details of how these past-due payment obligations will be met. (attach additional sheets if necessary)

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