Provider Data Intake FormAmeriHealth Caritas Texas Provider Data Intake Form 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1, entering your Entity Name as it appears on your W9. If applicable, include the IPA name and select the appropriate Category and Product Type from the provided options.
3. Fill in the Primary Contact details including Name, Email, Phone, and Address. Ensure all fields are completed accurately for effective communication.
4. Proceed to Section 2 where you will list all practice locations. For each location, provide the Group/Facility Name, Address, County, and contact information. Make sure to indicate if any services are provided at these locations.
5. In Section 3, indicate ADA compliance for each location by checking the relevant boxes based on accessibility features available.
6. Complete Section 4 by selecting services offered at each location and specifying age ranges served. Use checkboxes for clarity.
7. Finally, in Section 5, list practitioners associated with your practice locations. Include their names, specialties, languages spoken, and whether they are accepting new patients.

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