Medical Transportation Program Provider Application
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.
For information about Medicaid provider identifier requirements or the status of your enrollment, call the TMHP Contact Center toll-free at 1-800-925-9126. Thank you for applying to become an Medical Transportation Provider. ot e
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