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December 2016 Texas Medicaid Provider Procedures Manual

Section 1: Provider Enrollment and Responsibilities : 1.1 Provider Enrollment and Reenrollment : 1.1.9 Required Enrollment Forms : HHSC Medicaid Provider Agreement
The HHSC Medicaid Provider Agreement must be submitted by all providers who enroll in Texas Medicaid and must be signed by the provider who is applying for enrollment. If the applicant is an entity, a principal of the entity who has the authority to bind the entity to the requirements of the HHSC Provider Agreement must sign the agreement. “Principal” is defined in the following section.
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If the provider is city- or government-owned, the agreement must be signed by a person who is authorized under the city or government charter. This form is an agreement between HHSC and the provider performing services under the State Plan wherein the provider agrees to certain provisions as a condition of participation.
The person who signs the HHSC Medicaid Provider Agreement is certifying that all of the information in the application packet, including every completed Provider Information Form (PIF-1) and Principal Information Form (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.
TMHP must receive all of the pages of the HHSC Medicaid Provider Agreement in a single submission for a valid contract. If corrections are required on any page within the agreement, a new agreement with an original signature and date is required.

Texas Medicaid & Healthcare Partnership
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