Attachments

  Check, money order, or cashier’s check

If you are attesting: “I am submitting the application fee to Texas Medicaid by paper check, money order, or cashier’s check with this application," you must submit the check, money order, or cashier’s check by mail. 

Proof of Payment

If you are attesting: “I have already paid the application fee to Medicare, another state's Medicaid or CHIP Program and have been approved for enrollment", you must attach proof of application fee payment to another state's Medicaid or CHIP program.

Hardship Waiver Supporting Documentation

If you are attesting: "I am requesting an application fee waiver due to hardship", you must attach a letter and supporting documentation detailing the reason(s) you are unable to pay an application fee.

The supporting documentation may include but is not limited to historical cost reports, recent financial reports such as balance sheets and income statements, cash flow statements, tax returns, etc.

Assumed Name Certificate

If the entity’s "Doing Business As" (DBA) name, is provided and differs from the Legal Name According to the IRS, you must attach a copy of the "Assumed Name Certificate".

For Sole Proprietorships:

The Assumed Name Certificate is obtained from the County Clerk's office.

For Partnerships, C Corporations, S Corporations, Professional Associations, or Limited Liability Companies:

The Assumed Name Certificate is obtained from the Secretary of State's office.

If the entity does not have a DBA, this documentation is not required to be attached.

Internal Revenue Service (IRS) Exemption Letter

If you select Yes for the question "Do you have a 501(c)(3) Internal Revenue Exemption?", you must attach the IRS Exemption Letter.

The letter must be from the Internal Revenue Service (IRS) and must list a Tax ID that matches the Tax ID listed on the Substitute 
Form W-9.

Letters submitted from any organization other than the IRS are not acceptable (includes Texas Sales Tax Exempt Letters).

Articles or Certificate of Incorporation

Certificate of Fact

Certificate of Formation or Certificate of Filing

Certificate of Authority or Certificate of Registration

If you select any of the following for the Federal tax classification on the Substitute Form W-9, attach the Certificate of Filing/Formation/Authority or its equivalent based on the year of formation.

C Corporation, S Corporation, Professional Association or LLC.

Out-of-state corporations not providing services in the state of Texas are exempt.

§  The name on this form must match the Name on the Substitute Form W-9.

Forms by year of creation:

For corporations formed prior to January 1, 2006: Articles of Incorporation, Certificate of Incorporation, or Certificate of Fact.

For corporations formed on or after January 1, 2006: Certificates of Formation or Certificate of Filing.

For corporations registered in a state other than Texas: Certificate of Authority or Certificate of Registration.

Shows the legal name of the corporation and is proof that it is registered to do business in the State of Texas.

Providers must obtain the appropriate form from the Office of the Secretary of the State.

Out-of-state corporations not providing services in the state of Texas are exempt.

Franchise Tax Account Status

If you select C Corporation, S Corporation, Professional Association or LLC for the Federal tax classification on the Substitute Form W-9, and are not exempt from franchise tax, the provider attach a copy of the Franchise Tax Account Status form. The status must reflect Active for the right to transact business in Texas. 

Exceptions:

Corporations that are nonprofit are exempt from the franchise tax and do not require this form.

These corporations have a "501(c)(3) IRS Exemption.”

Out-of-state corporations not providing services in the state of Texas are exempt

Background information:

The Texas Legislature passed a House Bill that provides that, after August 31, 1987, a corporation that is delinquent in franchise tax may not be awarded a contract by the state or agency of the state and may not be granted a license or permit by the state or agency of the state.

Partnership Agreement and Statement

If you select Partnership for the Federal tax classification on the Substitute Form W-9, you attach a copy of:

The partnership agreement, or a written statement identifying no written partnership agreement exists.

A statement of which partner is responsible for any amounts owed to VDP if the pharmacy ceases business or stops accepting Medicaid.

Organizational Structure Chart

If you select Partnership, C Corporation, S Corporation, Professional Association or LLC for the Federal tax classification on the Substitute Form W-9, you must attach an organizational structure chart showing all individuals or organizations holding ownership interests in the entity.

Copy of License

A current copy of the enrolling provider’s license.

The license cannot expire within 30 days of submission of the application/PEMS request.

Copy of Certification

A current copy for any of the following certifications (as required)

Clinical Laboratory Improvement Amendments (CLIA)

American Midwifery Certification

Rehabilitation Engineering and Assistive Technology

National Registry of Rehabilitation Technology

Dental Anesthesiology Certification(s) & Portability

Certificate of Mammography

Copy of Accreditation

A current copy of the Clinical Laboratory Improvement Amendments (CLIA)

Disclosure Explanation

If you select "Yes" for any of the "disclosure" questions, you must attach the appropriate documentation related to the explanation as indicated in PEMS.

 If disclosure is for a prior exclusion, provide reinstatement documentation from the Office of Inspector General (OIG). 

Applicant to provide attachment of disciplinary and non-disciplinary actions related to the license authority.

Applicant to add voluntary surrender/board order of licensure.

Applicant to add supporting documentation as proof of compliance with repayment plan.

Applicant to add supporting documentation for proof of criminal history.

Applicant to attach all relevant documentation or provide an explanation why the documentation is not available and where it can be obtained.

Out of State Criteria

Documentation of proof meeting one of the Out of State Criteria, if not located within 50 miles of the Texas State border according to Texas Administrative Code TAC § 352.17.

If the provider is a permanent out-of-state pharmacy, submit a letter detailing the additional benefit(s) or service(s) it can provide to a Texas Medicaid recipient on company letterhead.

Disclosure Explanation

If you select "Yes" for any of the Disclosure questions, you must attach the appropriate documentation related to the explanation as indicated on the PEMS Owners/Creditors/Principals Disclosures sub-page.

If disclosure is for a prior Exclusion, provide Reinstatement documentation from OIG.

Principal to provide attachment of disciplinary and non-disciplinary actions related to the license authority.

Principal to add supporting documentation of voluntary surrender order of licensure.

Principal to add supporting documentation as proof of compliance with repayment plan.

Principal to add supporting documentation for proof of criminal history.

Principal to attach all relevant documentation or provide an explanation why the documentation is not available and where it can be obtained.

I-9 Documentation

If an owner/creditor/principal is not a U.S. Citizen, the principal must attach unexpired documentation that establishes both Identity and Employment Authorization.

For the full list of acceptable documents, please visit https://www.uscis.gov/i-9-central/acceptable-documents/list-documents/form-i-9-acceptable-documents

Direct Deposit (Form 74-176)

This form may be used by vendors, individual recipients or state employees to receive payments from the state of Texas by direct deposit or to change/cancel existing direct deposit information.

Application for Payee Identification Number (Form AP-152)

  Check, money order, or cashier’s check

If you are attesting: “I am submitting the application fee to Texas Medicaid by paper check, money order, or cashier’s check with this application," you must submit the check, money order, or cashier’s check by mail. 

Proof of Payment

If you are attesting: “I have already paid the application fee to Medicare, another state's Medicaid or CHIP Program and have been approved for enrollment", you must attach proof of application fee payment to another state's Medicaid or CHIP program.

Hardship Waiver Supporting Documentation

If you are attesting: "I am requesting an application fee waiver due to hardship", you must attach a letter and supporting documentation detailing the reason(s) you are unable to pay an application fee.

The supporting documentation may include but is not limited to historical cost reports, recent financial reports such as balance sheets and income statements, cash flow statements, tax returns, etc.

Assumed Name Certificate

If the entity’s "Doing Business As" (DBA) name, is provided and differs from the Legal Name According to the IRS, you must attach a copy of the "Assumed Name Certificate".

For Sole Proprietorships:

The Assumed Name Certificate is obtained from the County Clerk's office.

For Partnerships, C Corporations, S Corporations, Professional Associations, or Limited Liability Companies:

The Assumed Name Certificate is obtained from the Secretary of State's office.

If the entity does not have a DBA, this documentation is not required to be attached.

Internal Revenue Service (IRS) Exemption Letter

If you select Yes for the question "Do you have a 501(c)(3) Internal Revenue Exemption?", you must attach the IRS Exemption Letter.

The letter must be from the Internal Revenue Service (IRS) and must list a Tax ID that matches the Tax ID listed on the Substitute 
Form W-9.

Letters submitted from any organization other than the IRS are not acceptable (includes Texas Sales Tax Exempt Letters).

Articles or Certificate of Incorporation

Certificate of Fact

Certificate of Formation or Certificate of Filing

Certificate of Authority or Certificate of Registration

If you select any of the following for the Federal tax classification on the Substitute Form W-9, attach the Certificate of Filing/Formation/Authority or its equivalent based on the year of formation.

C Corporation, S Corporation, Professional Association or LLC.

Out-of-state corporations not providing services in the state of Texas are exempt.

§  The name on this form must match the Name on the Substitute Form W-9.

Forms by year of creation:

For corporations formed prior to January 1, 2006: Articles of Incorporation, Certificate of Incorporation, or Certificate of Fact.

For corporations formed on or after January 1, 2006: Certificates of Formation or Certificate of Filing.

For corporations registered in a state other than Texas: Certificate of Authority or Certificate of Registration.

Shows the legal name of the corporation and is proof that it is registered to do business in the State of Texas.

Providers must obtain the appropriate form from the Office of the Secretary of the State.

Out-of-state corporations not providing services in the state of Texas are exempt.

Franchise Tax Account Status

If you select C Corporation, S Corporation, Professional Association or LLC for the Federal tax classification on the Substitute Form W-9, and are not exempt from franchise tax, the provider attach a copy of the Franchise Tax Account Status form. The status must reflect Active for the right to transact business in Texas. 

Exceptions:

Corporations that are nonprofit are exempt from the franchise tax and do not require this form.

These corporations have a "501(c)(3) IRS Exemption.”

Out-of-state corporations not providing services in the state of Texas are exempt

Background information:

The Texas Legislature passed a House Bill that provides that, after August 31, 1987, a corporation that is delinquent in franchise tax may not be awarded a contract by the state or agency of the state and may not be granted a license or permit by the state or agency of the state.

Partnership Agreement and Statement

If you select Partnership for the Federal tax classification on the Substitute Form W-9, you attach a copy of:

The partnership agreement, or a written statement identifying no written partnership agreement exists.

A statement of which partner is responsible for any amounts owed to VDP MEDICAREONLY if the pharmacy ceases business or stops accepting Medicaid.

Organizational Structure Chart

If you select Partnership, C Corporation, S Corporation, Professional Association or LLC for the Federal tax classification on the Substitute Form W-9, you must attach an organizational structure chart showing all individuals or organizations holding ownership interests in the entity.

Copy of License

A current copy of the enrolling provider’s license.

The license cannot expire within 30 days of submission of the application/PEMS request.

Copy of Certification

A current copy for any of the following certifications (as required)

Clinical Laboratory Improvement Amendments (CLIA)

American Midwifery Certification

Rehabilitation Engineering and Assistive Technology

National Registry of Rehabilitation Technology

Dental Anesthesiology Certification(s) & Portability

Certificate of Mammography

Copy of Accreditation

A current copy of the Clinical Laboratory Improvement Amendments (CLIA)

Copy of License

A current copy of the enrolling provider’s license.

The license cannot expire within 30 days of submission of the application/PEMS request.

Disclosure Explanation

If you select "Yes" for any of the "disclosure" questions, you must attach the appropriate documentation related to the explanation as indicated in PEMS.

 If disclosure is for a prior exclusion, provide reinstatement documentation from the Office of Inspector General (OIG). 

Applicant to provide attachment of disciplinary and non-disciplinary actions related to the license authority.

Applicant to add voluntary surrender/board order of licensure.

Applicant to add supporting documentation as proof of compliance with repayment plan.

Applicant to add supporting documentation for proof of criminal history.

Applicant to attach all relevant documentation or provide an explanation why the documentation is not available and where it can be obtained.

Out of State Criteria

Documentation of proof meeting one of the Out of State Criteria, if not located within 50 miles of the Texas State border according to Texas Administrative Code TAC § 352.17.

If the provider is a permanent out-of-state pharmacy, submit a letter detailing the additional benefit(s) or service(s) it can provide to a Texas Medicaid recipient on company letterhead.

Copy of HRSA Notice of Grant Award (NOGA) and letter

FQHC enrollments require this document to be submitted.

Not required for an FQHC Lookalike

Certain newly enrolling and re-enrolling providers must obtain a surety bond as a condition of enrollment into Texas Medicaid.

This Surety Bond must meet the requirements in proposed Title 1, Texas Administrative Code (TAC) §352.15 in the amount of no less than $50,000 with their provider enrollment application for each enrolled practice location

At the time of enrollment or reenrollment, providers must submit the State of Texas Medicaid Provider Surety Bond Form with original signatures and a copy of the Power of Attorney document from the surety company that issued the bond.

This bond must be separate from a CMS Surety

Out of State Criteria

A copy of your Liability Insurance documentation will be required dependent on your Provider Type.

If the provider is a permanent out-of-state pharmacy, submit a letter detailing the additional benefit(s) or service(s) it can provide to a Texas Medicaid recipient on company letterhead.

Disclosure Explanation

If you select "Yes" for any of the Disclosure questions, you must attach the appropriate documentation related to the explanation as indicated on the PEMS Owners/Creditors/Principals Disclosures sub-page.

If disclosure is for a prior Exclusion, provide Reinstatement documentation from OIG.

Principal to provide attachment of disciplinary and non-disciplinary actions related to the license authority.

Principal to add supporting documentation of voluntary surrender order of licensure.

Principal to add supporting documentation as proof of compliance with repayment plan.

Principal to add supporting documentation for proof of criminal history.

Principal to attach all relevant documentation or provide an explanation why the documentation is not available and where it can be obtained.

I-9 Documentation

If an owner/creditor/principal is not a U.S. Citizen, the principal must attach unexpired documentation that establishes both Identity and Employment Authorization.

For the full list of acceptable documents, please visit https://www.uscis.gov/i-9-central/acceptable-documents/list-documents/form-i-9-acceptable-documents

Out of State Criteria

Documentation of proof meeting one of the Out of State Criteria, if not located within 50 miles of the Texas State border according to Texas Administrative Code TAC § 352.17.

If the provider is a permanent out-of-state pharmacy, submit a letter detailing the additional benefit(s) or service(s) it can provide to a Texas Medicaid recipient on company letterhead.

Direct Deposit (Form 74-176)

This form may be used by vendors, individual recipients or state employees to receive payments from the state of Texas by direct deposit or to change/cancel existing direct deposit information.

Application for Payee Identification Number (Form AP-152)

This form must be submitted by every person (sole owner, individual recipient, partnership, corporation, or other organization) who intends to bill agencies of the state government for goods, services provided, refunds, public assistance, etc.

Copy of License

A current copy of the enrolling provider’s license.

The license cannot expire within 30 days of submission of the application/PEMS request.

Copy of Certification

A current copy for any of the following certifications (as required)

Clinical Laboratory Improvement Amendments (CLIA)

American Midwifery Certification

Rehabilitation Engineering and Assistive Technology

National Registry of Rehabilitation Technology

Dental Anesthesiology Certification(s) & Portability

Certificate of Mammography

Copy of Accreditation

A current copy of the Clinical Laboratory Improvement Amendments (CLIA)

Disclosure Explanation

If you select "Yes" for any of the "disclosure" questions, you must attach the appropriate documentation related to the explanation as indicated in PEMS.

 If disclosure is for a prior exclusion, provide reinstatement documentation from the Office of Inspector General (OIG). 

Applicant to provide attachment of disciplinary and non-disciplinary actions related to the license authority.

Applicant to add voluntary surrender/board order of licensure.

Applicant to add supporting documentation as proof of compliance with repayment plan.

Applicant to add supporting documentation for proof of criminal history.

Applicant to attach all relevant documentation or provide an explanation why the documentation is not available and where it can be obtained.

Out of State Criteria

Documentation of proof meeting one of the Out of State Criteria, if not located within 50 miles of the Texas State border according to Texas Administrative Code TAC § 352.17.

If the provider is a permanent out-of-state pharmacy, submit a letter detailing the additional benefit(s) or service(s) it can provide to a Texas Medicaid recipient on company letterhead.