TX Group Provider Record ID Information Form Packet 2018-2025 free printable template
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C. Survival. This provision shall survive termination of this Agreement. IN WITNESS WHEREOF the undersigned have executed this Contract to be effective as of the City St Zip BCBSTX A scanned imaged electronic photocopy or stamp of the signatures hereunder shall have the same force and effect as an originally executed signature Authorized Signature Name Shara McClure Title Divisional Senior Vice President TX Health Care Delivery Title Date NPI Please Print or Type Please check appropriate box...
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How to fill out TX Group Provider Record ID Information Form
01
Obtain the TX Group Provider Record ID Information Form from the relevant Texas health authority website or office.
02
Ensure you have all required documentation before starting the form.
03
Fill out the provider's legal name in the designated field.
04
Enter the provider's mailing address accurately.
05
Include the provider's National Provider Identifier (NPI) if applicable.
06
Provide the group’s tax identification number (TIN).
07
List all affiliated providers with their corresponding NPI numbers.
08
Review the completed form for accuracy and completeness.
09
Sign and date the form where required.
10
Submit the form as instructed (online or by mail) to the appropriate health authority.
Who needs TX Group Provider Record ID Information Form?
01
Healthcare providers wishing to enroll in Texas Medicaid programs.
02
Group practices seeking to receive Medicaid reimbursements.
03
Any organization providing medical services that operates under a group practice.
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What is TX Group Provider Record ID Information Form?
The TX Group Provider Record ID Information Form is a document used to collect and record essential identification information about healthcare providers operating within a specific group in Texas.
Who is required to file TX Group Provider Record ID Information Form?
Healthcare providers and organizations operating as group providers in Texas are required to file the TX Group Provider Record ID Information Form.
How to fill out TX Group Provider Record ID Information Form?
To fill out the TX Group Provider Record ID Information Form, provide accurate details such as the group provider's name, contact information, and the identification numbers required, ensuring all sections are completed as instructed.
What is the purpose of TX Group Provider Record ID Information Form?
The purpose of the TX Group Provider Record ID Information Form is to maintain an official record of healthcare provider groups for regulatory compliance and to streamline communication between providers and the Texas healthcare system.
What information must be reported on TX Group Provider Record ID Information Form?
The TX Group Provider Record ID Information Form must report information including the group provider's legal name, address, contact information, provider type, and any relevant identification numbers.
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