Tmhp 2026

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4.1 out of 5

50 votes

The document is a Provider Information Change Form for Texas Medicaid fee-for-service and CSHCN Services Program providers to update their enrollment details. It outlines the necessary information required, such as provider identifiers, addresses, tax information, and types of changes being made. The form must be completed accurately and submitted with additional documentation as needed, including a W-9 form for address changes.

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Click ‘Get Form’ to open the Provider Information Change Form in the editor.
Begin by entering the date at the top of the form. Ensure you provide your Nine-Digit Texas Provider Identifier (TPI) and National Provider Identifier (NPI) accurately.
Fill in your provider name, primary taxonomy code, and any additional TPIs that share the same information. Be thorough to avoid processing delays.
Complete the physical address section, ensuring it is not a PO Box. If applicable, include a copy of the Medicare letter if changing ZIP Codes for Ambulatory Surgical Centers.
Provide your accounting/mailing address and ensure to attach a W-9 form if changes are made here.
Indicate the type of change by checking the appropriate box and provide any necessary comments for clarification.
Finally, sign and date the form before submitting it via mail or fax to TMHP as indicated at the bottom of the form.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (101 Votes)
2016	4.8 Satisfied (129 Votes)
2012	4.1 Satisfied (50 Votes)

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