Provider Data Intake FormAmeriHealth Caritas Texas Provider Data Intake Form 2026

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. Include the IPA name if applicable 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 to list all practice locations. For each location, provide the Group/Facility Name, Address, County, and contact information. Make sure to include NPI or Atypical ID where required.
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 provided at each location and indicating age ranges served. This section is crucial for service categorization.
7. Finally, fill out Section 5 with practitioner details including names, specialties, and whether they are accepting new patients. Attach additional rosters if necessary.

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