Instructions for Completing the Provider Demographics page

• Note: This is a Revalidation page. If you would like information about another application type, Click Here.
• If applicable, enter all of your existing Texas Medicaid Texas Provider Identifiers (TPIs) in the “Existing Medicaid Texas Provider Identifiers (TPIs)” field.
• Select “Yes” or “No” for “Do you want to be a limited provider?”
• Limited providers are primary care providers who manage the medical care of clients in the Limited Program. The Health and Human Services Inspector General (IG) reviews clients for suspected fraud, abuse, or misuse of Medicaid benefits and places clients in the Limited Program if IG identifies any issues. Limited providers determine the appropriateness and frequency of Medicaid services for clients in the Limited Program. Limited providers also refer clients to other providers when it is medically necessary.
• Enter your Last Name.
• The last name that you enter must match the last name on your professional license or certification.
• If you are also enrolled in Medicare, the last name that you enter must match the last name you have on file with Medicare.
• If you want to change your last name after you submit this application, you must submit a new Provider Agreement.
• Note: This field will be automatically populated for existing enrollments and reenrollments. The field cannot be changed.
• Confirm the enrolling provider’s Last Name.
• Enter your maiden name (if applicable).
• Confirm the enrolling provider’s maiden name (if applicable).
• Enter any name variations, aliases, or nicknames that you use (if applicable).
• Confirm any name variations, aliases, or nicknames that the enrolling provider may use (if applicable).
• Enter your First Name.
• The first name that you enter must match the first name on your professional license or certification.
• If you are also enrolled in Medicare, the first name that you enter must match the last name you have on file with Medicare.
• If you want to change your first name after you submit this application, you must submit a new Provider Agreement.
• Note: This field will be automatically populated for existing enrollments and reenrollments. The field cannot be changed.
• Confirm the enrolling provider’s First Name.
• Enter the Group or Facility Name.
• If the group or facility is licensed or certified, the Group or Facility name that you enter must match the name on your professional license or certification.
• If the group or facility is enrolled in Medicare, the group or facility name that you enter must match the group or company name that is on file with Medicare.
• If you want to change your group or facility name after you submit this application, you must submit a new Provider Agreement.
• Note: This field will be automatically populated for existing enrollments and reenrollments. The field cannot be changed.
• Select a Title/Degree from the drop-down menu.
• This field is not required for groups and facilities.
• Enter a Business Name/Doing Business As name (if applicable).
• This field is only for facilities and groups.
• The doing business as (DBA) name that you enter must match the name that you entered in the “Business Name” field on the IRS W-9 form.
• Confirm your “Business Name/Doing Business As name” (if applicable).
• Enter your or the enrolling provider’s Social Security number.
• This field is not required for groups and facilities.
• Confirm the Social Security number.
• This field is not required for groups and facilities.
• Enter your Employer’s Tax Identification Number (TIN).
• The TIN that you enter must match the TIN that you entered on the IRS W-9 form.
• This field is optional for individuals and sole proprietors who are using their Social Security number.
• Ordering and referring providers must leave this field blank.
• If you entered a TIN that is the same as your Social Security number, check the box for “Same as SSN.”
• Confirm your Employer’s Tax Identification Number (TIN).
• Enter the Legal Name According to the IRS.
• The legal name that you enter must match the name that you entered on the IRS W-9 form.
• Confirm the Legal Name According to the IRS.
• Enter your or the enrolling provider’s Date of Birth.
• This field is not required for groups and facilities.
• Confirm the Date of Birth.
• This field is not required for groups and facilities.
• Enter your Email Address.
• Enter a second Email Address and, if applicable, a Provider Business Web Site Address.
• A second email address and website address will make it much easier to contact you if there are any issues with your other contact information.
• Select your Communication Preference.
• Select an address from your Group’s addresses.
  •   Click Apply to physical address to complete the physical address field.
  •   Click Apply to accounting/billing address to complete the accounting/billing address field.
• Enter the Physical Address at which you render services.
  • Verify that the address that you entered matches the address where services are rendered to clients. You must not enter the accounting, corporate, or mailing address into the “Physical Address” field.
  • If you want to change your address after you have submitted this application, you must submit a new Provider Agreement.
  • Important: If a site visit is required for enrollment, but it cannot be conducted because the physical address isn’t correct, the enrollment application will be denied.
  • If you are enrolled in Medicare, the Physical Address must match the practice location that is on file with Medicare.
  • The physical address that you enter must match the physical address that is on file for the group.
  • The physical address that you enter must match the physical address that is on file for your Texas Medicaid TPI.
  • Note: This field will be automatically populated for existing enrollments and reenrollments.
  • If you want to change the address, check the box for “Click to change address,” enter the updated address, and then click OK.
  • Note: A deficiency will exist if the application is for a performing provider and the address is not on file for the group.
  •   Click Validate Address.
• Confirm the Physical Address.
  • Verify that the address listed matches the address where services are rendered to clients. It must not match the accounting, corporate, or mailing address.
  • If you want to change your address after you have submitted this application, you must submit a new Provider Agreement.
  • Important: If a site visit is required for enrollment, but it cannot be conducted because the physical address isn’t correct, the enrollment application will be denied.
  • If you are enrolled in Medicare, the Physical Address must match the practice location that is on file with Medicare.
  • The physical address must match the physical address that is on file for the group.
  • The physical address that you enter must match the physical address that is on file for your Texas Medicaid TPI.
  •   If you want to change the address, check the box for Click to change address, enter the updated address, and then click OK.
  •   If you updated the address, click Validate Address.
• Enter your Accounting/Billing Address (if applicable), or click Same as Physical.
  • If you want to change your accounting or billing address after you submit your application, you must submit a new Provider Agreement.
  • Note: This field will be automatically populated for existing enrollments and reenrollments.
  •   If you want to change the address, check the box for “Click to change address,” and enter the updated address.
  •   Click Validate Address.
• Verify the Accounting/Billing Address (if applicable), or click Same as Physical.
  •  If you want to change your accounting or billing address after you submit your application, you must submit a new Provider Agreement.
  •   If you want to change the address, check the box for “Click to change address,” and enter the updated address.
  •  Click Validate Address.
• Enter the Phone Number and, if applicable, the Fax Number/Business Fax.
  • This field is only required if your accounting address is different from your physical address.
  •   Select an option for your relationship to the accounting address.
  •   If you select “Other,” you must explain the relationship in the box provided.
• Select a reason from the “Select a reason for applying to join Texas State Health-Care Programs” drop-down menu.
• Click Add Surety Bond, and complete the fields.
  •   Enter in Surety Bond Number, Surety Company Name, Issue and Expiration Date, Duration of Bond (in months), and Surety Bond Amount.
• Select answers to Accepting New Clients, Gender Limitations, and Client Age Restrictions.
• Click the counties that you serve, and click Add.
• Select “Yes” or “No” for “Will you Perform Healthy Texas Women Services?”
  • This question will only appear to eligible providers.
  •   If you selected “Yes,” check the “Yes, I Affirm” box, and answer the HTW Women's Health and Family Planning Services question.
  •   Select “Yes” for “Yes, I affirm that the statements listed in the certification are true and correct.”
  •   Click Click here to view your certification statements.
• Select “Yes” or “No” for “Will you provide HTW services, HTW Plus services, or both at this location?”
  • Note: HTW offers women's health and family planning services, including cancer screenings, testing/treatment for infections, and birth control. In addition, HTW Plus covers testing and treatment for cardiovascular and coronary conditions, as well as treatment for behavioral health conditions for recently pregnant women.
• Select “Yes” or “No” for “If you provide HTW or HTW Plus services at this location, do you want to be included in online provider lookup tools?”
  • Note: HTW clients use these tools to find HTW providers.
  •   If you selected ‘Yes’, your address and your contact information will be made available on the HTW Online Provider Lookup and the Texas Medicaid Provider Online Lookup. Please be sure this information is up-to-date.
• Select “Yes” or “No” for “Are you only enrolling to provide services to clients in the Children's Health Insurance Program (CHIP)?”
• Select “Yes” or “No” for “I would like my provider information to be visible on the Texas Medicaid Online Provider Lookup (OPL).”
• Clients can use the OPL to find your practice information, including locations, services offered, and whether or not you are seeing new clients.
• Continue and Save.