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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:

Revalidation Principal Information Form (PIF-2)

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

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

Note: This page does not apply to Performing Providers.

Note: This is a Revalidation page. If you would like information about another application type, Click Here.

  • Select Person or Entity.
    • If you selected “Entity”:
      •   Enter the federal tax classification that is listed on your IRS form W9.
      •   Enter the legal name as listed on the IRS form W9.
      •   Enter the address as shown on the IRS form W9.
      •   Provide an explanation in the box below the question “how is the entity organized to conduct business or activities?”
      •   Select “Yes” or “No” for “Do you conduct business under an assumed name?”
        • An “assumed name” is a name other than the legal name of the business, such as the “doing business as” name that is listed on your IRS form W-9.
      •   If you answered “Yes,” enter the name in the “Assumed Name/Doing Business As” field.
  • Select Principal or Subcontractor.
  • Section: Name
  • Complete the “Last Name/Company Name” and “First Name” fields.
  • Complete the “Maiden Name,” “Other Alias,” and “Middle Initial” fields if you completed the “First Name” field.
  • Complete the “Percent Owned” field.
  • If the PIF-2 is being completed for a person or entity that owns a percentage of the provider, enter the percent of the provider that is owned by the person or entity. If the person or entity does not own a percentage of the provider, enter a zero.
  • Section: Address
  • Complete the “Physical Address” field.
  • Complete the “Accounting/Billing Address” field (if applicable).
  • Section: Accounting Address Relationship
  • Answer the question “If your accounting address is different from your physical address, please indicate your relationship to the Accounting Address.”
  • Section: Professional Healthcare Licensing Information
  • If the principal or subcontractor has a professional healthcare license, complete the “Professional License State,” “Professional License Number,” “Professional Licensing Board,” “Professional License Issue Date,” and “Professional License Expiration Date” fields.
  • If you selected “person” at the beginning of the form, complete the “Social Security Number” field.
  • If you selected “entity” at the beginning of the form, complete the “Federal Tax ID” field.
  • Select “Yes” or “No” for “Do you have one or more professional licenses, accreditations, or certifications?”
    •   If you answered “Yes,” click Add License/Certification/Accreditation.
  • List all of your professional health-care licenses, accreditations, and certifications.
    •   Complete the “Issuer” field.
    •   Complete the “Number” field.
    •   Complete the “Issue Date” field.
    •   Complete the “Expiration Date” field.
    •   Click Done.
  • Click Continue and Save.
 
Contents
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