Common Contracts
2 similar Medicaid Provider Agreement contracts
HHSC Medicaid Provider AgreementMedicaid Provider Agreement • September 27th, 2018
Name of provider enrolling: Medicaid TPI: (if applicable) Medicare provider ID number: (if applicable) Physical address (where health care is rendered): Providers MUST enter the physical address where the services are rendered to clients. If the accounting, corporate, or mailing address is entered in this physical address field, the application may be denied.Number Street Suite City State ZIP Accounting/billing address: (if applicable)Number Street Suite City State ZIP
HHSC Medicaid Provider Agreement (THSteps Dental)Medicaid Provider Agreement • December 30th, 2014
Name of provider enrolling: Medicaid TPI: (if applicable) Medicare provider ID number: (if applicable) Physical address (where health care is rendered): Providers MUST enter the physical address where the services are rendered to clients. If the accounting, corporate, or mailing address is entered in this physical address field, the application may be denied.Number Street Suite City State ZIP Accounting/billing address: (if applicable)Number Street Suite City State ZIP
