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 .
Transportation Subcontractor (Demand Response): A profit or non-profit entity enrolled through the Texas Medicaid & Healthcare Partnership (TMHP) for participation status as an NEMT service provider, that may be enlisted by a managed transporation organization. Managed Transportation Organization (MTO): A transportation broker awarded
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