Medical Transportation Program Provider Application

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REV. XIMedical Transportation Program Provider Application Revised Date: 12/31/2019 | Effective Date: 01/01/2020Table of ContentsIntroduction ........................................ ........................................ ................1Application Contact Information ........................................ .......................................6 Application Payment Form ........................................ ........................................ ...7Medical Transportation Provider Enrollment Application ........................................ ...............8Disclosure of Ownership and Control Interest Statement ........................................ ..............9MTP Principal Information Form (MTP-PIF1) For Entities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14MTP Principal Information Form (MTP-PIF2) For Transportation Provider A: Additional Forms.

Page 3 Application Instructions Revised Date: 12/31/2019 EThective Date: 01/01/2020 Application Instructions Required Forms for Medical Transportation Provider Enrollment To avoid any delay of the enrollment process, use this sheet as a checklist. For assistance with completing these forms, call the TMHP Contact Center at 1-800-925-9126.

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