Transcription of Provider Information Change Form - TMHP
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Provider Information Change Form - TMHP
Provider Information Change form Instructions F00114 Page 1 of 2 Revised: 10/18/2017 | Effective: 11/01/2017 General Instructions Texas Medicaid and other state health-care program providers can use this form to update the enrollment Information on file with tmhp . Submit only one form for each Change you would like to make. For example, submit one form to update your address Information ; submit two forms to update your address Information and any other updates (demographic Information , Federal Tax ID number, communication preferences, etc.). Do not return this instructions page. Fax completed forms and all other required documents (if applicable) to 512-514-4214 or mail to: tmhp Provider Enrollment PO Box 200795 Austin, TX 78720-0795 Reminder: Provider enrollment Information can also be updated electronically in the Provider Information Management System (PIMS) that is accessible through My Account at Provider Information Provide your name, primary taxonomy code, a
Provider Information Change Form Instructions F00114 Page 1 of 2 Revised: 10/18/2017 | Effective: 11/01/2017 General Instructions Texas Medicaid and other state health-care program providers can use this form to update the enrollment information on
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