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December 2016 Texas Medicaid Provider Procedures Manual

Section 1: Provider Enrollment and Responsibilities : 1.4 Provider Reenrollment : 1.4.2 Provider Status (Individual, Group, Performing Provider, or Facility)

1.4.2
Providers leaving group practices must send a signed letter or a Provider Information Change Form to TMHP that states the date of deactivation. The letter should include the provider identifier, effective date of deactivation, and the group’s provider identifier. The letter should be signed by an authorized representative of the group or the individual provider leaving the group. If the provider is joining a new group practice has changed from a group practice to an individual enrollment or vice versa, the provider must complete and submit a new Texas Medicaid Provider Enrollment Application to request enrollment with the new status information.

Texas Medicaid & Healthcare Partnership
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