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2.1.4.2 Provider Information Form (PIF-1), Principal Information Form (PIF-2), and Disclosure of Ownership Form
A PIF-1, PIF-2, and Disclosure of Ownership form must be completed by all providers or the owner, officer, director, or principal applying for CSHCN Services Program enrollment more than 1 year from their Texas Medicaid enrollment date. The Disclosure of Ownership form is submitted by all providers, excluding the performing providers of a group. This form provides the appropriate information to enroll the provider as a sole proprietor, corporation, partnership, or nonprofit organization. The PIF-1 must be completed by all providers enrolling in the CSHCN Services Program. A separate PIF-2 must be completed by each principal of the provider before enrollment in the CSHCN Services Program. Principals of the provider include all of the following:
• An owner with a direct or indirect ownership or control interest of five percent or more.
•Corporate officers and directors
•Limited or nonlimited partners
•Shareholders of a professional corporation, professional association, limited liability company, or other legally designated entity.
•Any employee of the provider who exercises operational or managerial control over the entity, or who directly or indirectly conducts the day-to-day operations of the entity.
These forms were designed across multiple state agencies to help meet the requirements set forth by the 75th Legislature's Senate Bill (S.B.) 30 to enhance the enrollment requirements for potential providers, meet federal requirements for enrollment, and improve the integrity of Texas State healthcare programs.
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