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).

• Applications received in response to re-enrollment Instructions: Complete Section A or Section B but not both. If you are using a Medicare certification number for this enrollment, complete section A. If you are not using a Medicare certification number for this enrollment, complete Section B: Section A.

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