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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:

Principal Information Form (PIF-2) Continued

Instructions for Completing the Principal Information Form (PIF-2) continued.

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

Note: This page does not apply to Performing Providers.

  • If you selected “Person,” select “Driver’s License Number” or “Other Number.”
  • This section is not required for principals that are entities.
  • Complete the “Driver’s License or Other Number” field.
  • If your driver’s license is expired or you do not have one, you can enter the number from any current government-issued photo identification card. The driver’s license or government-issued ID must be current on the date that the form is submitted.
  • This section is not required for principals that are entities.
  • Complete the “Expiration Date” field.
  • If your driver’s license is expired or you do not have one, you can enter the expiration date from any current government-issued photo identification card. The driver’s license or government-issued ID must be current on the date that the form is submitted.
  • This section is not required for principals that are entities.
  • Complete the “State Issuer” field.
  • If your driver’s license is expired or you do not have one, you can enter the state of issue from any current government-issued photo identification card or select Other. The driver’s license or government-issued ID must be current on the date that the form is submitted.
  • This section is not required for principals that are entities.
  • If you selected “Person,” complete the “Date of Birth” field and select a Gender.
  • This section is not required for principals that are entities.
  • Complete the “Previous Physical Address” field (if applicable).
  • Complete the “Previous Accounting/Billing Address” field (if applicable).
  • Complete the “Your title in the provider organization for which enrollment is being sought” field.
  • Complete the “Your duties to the provider organization” field.
  • List the duties (tasks or actions that you are required to perform) that you perform for the provider organization.
  • Select a role from the “Your role in the provider organization” list, and complete the “Effective Date” field.
  • Select the role that best describes your position, and enter your date of hire.
  • Important: If you are a licensed health-care professional, such as a doctor, nurse, dentist, or medical director, you must enter your license information in the Licensing Information section on the previous page.
  • Select “Yes” or “No” for “Do you have a relationship with a separate provider?”
  • If you selected “Yes,” explain the details in the box below the question.
  • List all of the TPIs, provider names, relationship to the provider, and physical locations under which you have billed or in which you were a principal. Include your current and any previous TPIs (if applicable).
  • If applicable, list all of the medical entities with whom you have a contractual relationship and, if known, the NPI/API and TPIs of each entity (if applicable).
  • You must answer all of the Sanction Questions.
    • Your answers should address all past and current sanctions.
    •  If you selected “Yes” for any of the sanction questions, you must explain the details in the box below the questions. Your explanation must include all of the following:
      • The date on which the incident that led to the sanction occurred
      • The state in which the incident that led to the sanction occurred
      • The agency that took the action
      • The program that was affected
  • Click Continue and Save.
 
Contents
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