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:
Provider Information Form (PIF-1) - Revalidation
Instructions for Completing the Provider Information Form (PIF-1).
Note: This is a Revalidation page. If you would like information about another application type, Click Here.
Enter your or the enrolling provider’s driver’s license or other number.
If your driver’s license is expired or you do not have one, any current government-issued photo identification card number can be entered.
This field is not required for groups or facilities.
Enter the expiration date of your driver's license or other form of identification.
Your driver’s license or other form of identification must be current on the date that you submit this application.
This field is not required for groups or facilities.
Select the state of issue for your driver’s license or other form of identification.
This field is not required for groups or facilities.
Choose your Gender.
This field is not required for groups or facilities.
Enter your Medicare Number (if applicable).
Warning: If your Medicare enrollment is pending, revoked, or deactivated, the Medicaid enrollment process will be delayed.
If you want to change your Medicare number after you submit this application, you must submit a new HHSC Provider Agreement.
Enter your Medicare Certification Date (if applicable).
Click Add under “Professional License/Certification/Accreditation” to add all of the professional licenses, certifications, or accreditations that are applicable for your provider type.
Select Licensure, from the drop-down menu.
Select an Issuer and State (out-of-state only).
Enter your license number, effective date, and expiration date.
Select Certification from the drop-down menu.
Enter the certification number that is applicable to your provider type.
Select Accreditation (CLIA) to enter your CLIA certification information, if it is applicable to your provider type.
Enter the address listed on your CLIA certification, if applicable.
Select Supervising/Referring/Consulting Physician and enter your supervising physician’s information. You must provide your supervising physician license information, if you are one of the following provider types:
Physician Assistant
Independent Lab
Certified Nurse Midwife
Maternity Services Clinic
Family Planning Agency
Texas Health Steps Medical (facility)
Hearing Aid
Radiological Clinic
Click Done
Select all of the options that are applicable for “TSBDE Sedation/Anesthesia Permits.”
You must submit a copy of your TSBDE Sedation or Anesthesia Permit.
Select “Yes” or “No” for “Do you plan to use a Third Party Biller to submit your Medicaid Claims?”
Third-party billers are persons, businesses, or entities (excluding state agencies) that submit claims on behalf of a provider, but are not the provider or an employee of the provider.
Note: If the field is grayed out, you do not need to complete it.
If you answered "Yes," enter the billing agent's information.
You must answer all of the sanction questions. Your answers should reflect both past and current sanctions.
If you selected "Yes" for any of the questions, you must explain the details in the box below the questions. Your explanation should include:
The date of the sanction.
The state in which the incident occurred.
The agency that took the action.
The program that was affected.
Contents
Go directly to a specific page's instructions by using the links below.
