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Provider Enrollment on the Portal Instructions
Important: You must be enrolled in Traditional Medicaid before enrolling in CSHCN or Texas Health Steps. Select "Add to an Existing Enrollment," then click "Apply Filters" if you would like instructions for adding CSHCN or Texas Health Steps to your existing enrollment.
Page Filters
These pages will guide you through each stage of the enrollment process using PEP. To customize this page's content, use the filters below and click the Apply Filters button.

Application Type:

Program(s):

Enrolling As:

Disclosure of Ownership

Instructions for Completing the Disclosure of Ownership and Control Interest Statement.

Note: This page does not apply to Ordering and Referring Providers.

Note: This page does not apply to Performing Providers.

  • All providers must complete the Disclosure of Ownership and Control Interest Statement except for:
    • Performing providers who are joining a group that is already enrolled in Texas Medicaid.
    • Providers that are already enrolled in Texas Medicaid and are enrolling in Texas Health Steps within one year of their TPI issue date.
    • SHARS providers.
  • Section I. Identifying Information
  • The “Legal Name according to the I.R.S.” and “DBA” fields will be prepopulated with the information that you provided in the Provider Demographics section.
  • Section II. Answer the following Questions by selecting “Yes” or “No”
    • Answer the questions in II (a) and II (b).
    • If you select “Yes” for any of the questions in sections II (a) and II (b), list the names and addresses of the relevant individuals or corporations under Section III.
    • Select your type of entity in III.
    • Select your tax classification entity from the list. You must only select one entity. Your selection must match the tax classification entity that you selected on your W-9.
    • If the tax classification entity that you entered on your W-9 form is not available in PEP, you must select Other and manually enter the tax entity classification that you selected on your W-9.
    • Important: Corporation must only be checked if “C-Corporation” has been indicated on your W-9 form
    • Note: For S Corporations, select "Other" and type "S Corporation" on the Disclosure of Ownership and W-9 forms.
    • Select “Yes” or “No” for “Do you have a 501(c)(3) Internal Revenue Exemption?”
    • If you selected “Yes,” you must submit a copy of your IRS exemption letter that is written on IRS letterhead with your application.
    • In section III (a), list the name of every other person or entity that has ownership of a controlling interest in the applicant entity, whether such ownership of the controlling interest is direct or indirect.
      • Click Add Owner to launch the Principal Information Form (PIF-2) for every other person or entity that has ownership of a controlling interest in the applicant entity, whether such ownership of the controlling interest is direct or indirect.
    • In section III (b), select “Yes” or “No” for “Do you currently have a creditor with a security interest in a debt that is owed by you?”
      • If you answered “Yes,” select “Yes” or “No” for “Is the creditor’s security interest protected by at least 5% of your property?”
        •   If you answered “Yes,” list each creditor that has a security interest in a debt that is owed by you if the creditor's security interest is protected by at least 5 percent of your property. All of the creditors that you list here must also complete a Principal Information Form (PIF-2).
    • In section III (c), if the disclosing entity is a corporation, each director must fill out a Principal Information Form (PIF-2).
      • Click Add Director to launch the Principal Information Form (PIF-2) for all directors of the corporation.

      • Section B Owners, Partners, Officers, Directors, and Principals

      You must identify the owners (sole proprietor or multiple owners), partners, officers, directors, and principals that you identified in the Principal Information Form (PIF-2). When identifying owners, you must include every individual who has 5% or more ownership in the entity, whether the ownership is direct or indirect.

      Medical Directors

      Ambulance providers are required to disclose the entity's Medical Director who must be a physician that is currently licensed in the state where services are provided. The medical director of an ambulance provider must complete the Principal Information Form (PIF-2).

      Authorized Representative

      The authorized representative is the person who will sign the HHSC Provider Agreement or any other provider agreement on behalf of a group or facility. The authorized representative must complete a PIF-2 form.

      Total Ownership

      The total of the ownership percentages of your entity must equal 100 percent. Non-profit 501(c)(3) entities do not have to have a total ownership percentage of 100 percent. If, for any reason, total ownership of an entity other than a 501(c)(3) does not equal 100 percent, you must submit a brief explanation of the discrepancy.

      Fingerprinting

      All owners that have 5 percent or more direct or indirect ownership interest of a high-categorical risk provider may be required to submit proof of fingerprinting to enroll in or revalidate their enrollment in Texas Medicaid. You will not be able to complete the enrollment process until you submit copies of all of the required individuals’ fingerprinting receipts to TMHP.

      If you have already completed the fingerprinting process for Medicare enrollment, Texas Medicaid, or another state's Medicaid program, you can upload your proof of fingerprinting in the Electronic Attachments section or by mail to:

      Texas Medicaid and Healthcare Partnership

      ATTN: Provider Enrollment

      PO Box 200795

      Austin, TX 78720-0795

    • Verify each person’s information by clicking PIF-2 under the “Link to PIF-2” column.
      • If the person is no longer an owner or principal, you may click Delete to remove the PIF-2.
    • Click Add another if you need to add Owners, Partners, Officers, Directors, and Principals who meet the definition of principal or subcontractor.
      • To revisit a PIF-2, click PIF-2 to re-launch the form.
    • Click Continue and Save.
     
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