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2012 Texas Medicaid Provider Procedures Manual

Volume 1, General Information : Section 1: Provider Enrollment and Responsibilities : 1.1 Provider Enrollment : 1.1.5 Required Enrollment Forms : 1.1.5.3 Provider and Principal Information Forms

1.1.5.3
The Provider Information Form (PIF‑1) must be completed by, or on behalf of, all providers. If the provider is an entity, the PIF-1 must be completed on behalf of the entity. A separate Principal Information Form (PIF‑2) must be completed by each principal of the provider.
Principals of the provider include all of the following:
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
Note:
The person who signs the HHSC Medicaid Provider Agreement is certifying that all of the information in the application packet, including every completed PIF-1 and PIF-2, is complete and correct. This includes a certification that every person who is required to complete a PIF-2 has done so, and all required PIF-2s are included with the application.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2011 American Medical Association. All rights reserved.