Provider Information Change Form PDF Details

In order to ensure our customers are receiving the highest level of service, it is necessary to periodically update our database with up-to-date provider information. To facilitate this process, we’ve created a provider information change form that allows you to easily make changes quickly and securely. This form is easy to fill out and submit, helping us ensure that your personal records are both accurate and complete when checked against other sources. Read on for more detailed information about what kinds of updates you can make using our provider information change form.

QuestionAnswer
Form NameProvider Information Change Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform changes medicaid, form tmhp services get, address change tmhp, tmhp

Form Preview Example

Provider Information Change Form

Texas Medicaid fee-for-service and Children with Special Health Care Needs (CSHCN) Services Program providers can complete and submit this form to update their provider enrollment file. Print or type all of the information on this form. Mail or fax the completed form and any additional documentation to the address at the bottom of the page.

Date :

/

/

 

 

 

Nine-Digit Texas Provider Identifier (TPI):

Provider Name:

 

 

National Provider Identifier (NPI):

Primary Taxonomy Code:

 

 

Atypical Provider Identifier (API):

Benefit Code:

 

 

 

 

List any additional TPIs that use the same provider information:

TPI:

TPI:

TPI:

TPI:

TPI:

TPI:

TPI:

TPI:

TPI:

 

 

Physical Address—The physical address cannot be a PO Box. Ambulatory Surgical Centers enrolled with Traditional Medicaid who change their ZIP Code must submit a copy of the Medicare letter along with this form.

Street address

 

City

 

County

State

Zip Code

 

 

 

 

 

 

 

Telephone: (

)

Fax Number: (

)

 

Email:

 

 

 

 

 

 

 

 

Accounting/Mailing Address—All providers who make changes to the Accounting/Mailing address must submit a copy of the W-9 Form along with this form.

Street Address

 

 

City

State

Zip Code

 

 

 

 

 

 

Telephone: (

)

Fax Number: (

)

Email:

 

 

 

 

 

 

 

Secondary Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

City

State

Zip Code

Telephone: (

)

Fax Number: (

)

Email:

 

Type of Change (check the appropriate box)

Change of physical address, telephone, and/or fax number

Change of billing/mailing address, telephone, and/or fax number

Change/add secondary address, telephone, and/or fax number

Change of provider status (e.g., termination from plan, moved out of area, specialist) Explain in the Comments field

Other (e.g., panel closing, capacity changes, and age acceptance)

Comments:

Tax Information—Federal Tax Identification (ID) Number and Name for the Internal Revenue Service (IRS)

Federal Tax ID number:

Effective Date:

Exact name reported to the IRS for this Tax ID:

Provider Demographic Information—Note: This information can be updated on www.tmhp.com.

Languages spoken other than English:

Provider office hours by location:

Accepting new clients by program (check one):

Accepting new clients

Current clients only

 

No

Patient age range accepted by provider:

 

Additional services offered (check one):

HIV

High Risk OB

Participation in Healthy Texas Women (HTW)? Yes

No

Patient gender limitations: Female

 

Male

Both

 

 

 

 

 

 

 

 

 

Signature and date are required or the form will not be processed.

 

 

 

 

 

 

 

Provider signature:

 

 

 

 

 

Date:

/

/

 

 

 

 

 

Mail or fax the completed form to: Texas Medicaid & Healthcare Partnership (TMHP)

 

Fax: 512-514-4214

 

Provider Enrollment

 

 

 

 

 

 

 

PO Box 200795

 

 

 

 

 

 

 

Austin, TX 78720-0795

 

 

 

 

 

 

 

F00114

REVISED DATE: 05/12/2016 | EFFECTIVE DATE: 07/01/2016

Instructions for Completing the

Provider Information Change Form

Signatures

•The provider’s signature is required on the Provider Information Change Form for any and all changes requested for individual provider numbers.

•A signature by the authorized representative of a group or facility is acceptable for requested changes to group or facility provider numbers.

Address

•Performing providers (physicians performing services within a group) may not change accounting information.

•For Texas Medicaid fee-for-service and the CSHCN Services Program, changes to the accounting or mailing address require a copy of the W-9 form.

•For Texas Medicaid fee-for-service, a change in ZIP Code requires copy of the Medicare letter for Ambulatory Surgical Centers.

Federal Tax Identification Number (TIN)

•Federal TIN changes for individual practitioner provider numbers can only be made by the individual to whom the number is assigned.

•Performing providers cannot change the Federal TIN.

Provider Demographic Information

An online provider lookup (OPL) is available, which allows users such as clients and providers to view information about Texas State Health-Care Programs providers. To maintain the accuracy of your demographic information, please visit the OPL at www.tmhp.com. Please review the existing information and add or modify any specific practice limitations accordingly. This will allow clients more detailed information about your practice.

General

•TMHP must have either the nine-digit Texas Provider Identifier (TPI), or the National Provider Identifier (NPI)/Atypical Provider Identifier (API), primary taxonomy code, physical address, and benefit code (if applicable) in order to process the change. Forms will be returned if this information is not indicated on the Provider Information Change Form.

•The W-9 form is required for all name and TIN changes.

•Mail or fax the completed form to:

Texas Medicaid & Healthcare Partnership (TMHP)

Provider Enrollment

PO Box 200795

Austin, TX 78720-0795

Fax: 512-514-4214

F00114

REVISED DATE: 05/12/2016 | EFFECTIVE DATE: 07/01/2016

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