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.

This form is required if the applicant is incorporated. This form must be notarized, and an original signature is required. This form cannot be faxed to TMHP. The following forms must be obtained from other sources and submitted with this application as appropriate for the requested provider type: Franchise Tax Status Page

  Form, Signature, Tmhp