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3.1.4 Provider Information Form (PIF-1) and Principal Information Form (PIF-2)
The PIF-1 must be personally completed by all providers enrolling in the CSHCN Services Program. A separate PIF-2 must be personally completed by each principal of the provider before enrollment in the CSHCN Services Program. Principals of the provider include an owner with a direct or indirect ownership or control interest of five percent or more. Principals also include corporate officers and/or directors, limited or nonlimited partners, or shareholders of a professional corporation, professional association, limited liability company, or other legally designated entity. Principals further include 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.
The PIF-1 and the PIF-2 must be signed by the individual to whom each applies or, in the case of an entity, signed by a principal of the entity, and notarized before the forms are returned to TMHP.
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 the Texas Medicaid Program.
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