Transcription of Medical Transportation Program Provider Application
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Medical Transportation Program Provider Application
REV. XIMedical Transportation Program Provider Application Revised Date: 12/31/2019 | Effective Date: 01/01/2020 Table of ContentsIntroduction ..1 Application Contact Information ..6 Application Payment Form ..7 Medical Transportation Provider Enrollment Application ..8 Disclosure of Ownership and Control Interest Statement ..9 MTP Principal Information Form (MTP-PIF1) For Entities ..14 MTP Principal Information Form (MTP-PIF2) For Transportation Provider A: Additional Forms ..A-1 Corporate Board of Directors B: tmhp Contact -1Do not return this page Page 1 Introduction Revised Date: 12/31/2019 | EThective Date: 01/01/2020 IntroductionDear Applicant:Thank you for your interest in becoming a Medical Transportation Provider .
provider responsibilities, benefits and limitations, and much more. The provider manual is updated monthly, and the current and archived provider manuals can be accessed on the TMHP web site at www.tmhp.com. Select “Medicaid Provider Manual” from the Providers page. There is no guarantee your application will be approved for processing.
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