Printable blank Medicaid Provider Enrollment Application

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Medicaid is a state program in the U.S. that provides financial support (read as medical coverage) for people with low income. When it comes to the Texas Medicaid Provider Enrollment Application form, it is used by healthcare professionals who wish to participate in state healthcare programs.

What You Need Texas Medicaid Provider Enrollment Application For

You need the Medicaid Provider Enrollment Application if you’re a provider looking to enroll to offer services to Medicaid. Prior to completing the application, make sure you gather the following information:

  • Active National Provider Identifier (NPI);
  • Professional license, certification, and DEA registration numbers;
  • Details regarding any final legal actions e.g., probation or suspension of a license. 

How to Fill out the Application

The Texas Medicaid Provider Enrollment Application consists of 87 pages that include the following major sections:

  • Introduction;
  • Enrollment requirements;
  • Application Instructions;
  • Medicare enrollment details;
  • Identification form;
  • The application itself. It features two sections. Section A requires you to specify your personal information and professional background in detail, including your name, address, phone number, as well as the specialty of practice, previous experience, etc. Section B features the Disclosure of Ownership and Control Interest Statement.

Prior to completing the Medicaid Provider Enrollment Application, make sure you study the Introduction section, along with the instructions on how to fill out the form. 

Organizations that Work with the Medicaid Provider Enrollment Application

  • Texas Health and Human Services Commission (HHSC)
  • Texas Medicaid & Healthcare Partnership (TMHP)

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