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 . Your participation in the Medical Transportation Program (MTP) is vital to the successful delivery of Texas Medicaid services, and we welcome your Application for Application must be completed in its entirety as outlined in the instructions below and will be reviewed by the Texas Health and Human Services Commission (HHSC) and the Texas Medicaid & Healthcare Partnership ( tmhp ).

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

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