HHSC Medicaid Ordering or Referring Provider AgreementMedicaid Ordering or Referring Provider Agreement • November 9th, 2016
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
