Dental Provider Enrollment Form

Texas Health Steps Dental Provider Enrollment Application

All information must be completed and contain a valid signature to be processed. If a question or answer does not apply, enter “N/A”. Original signatures only; copies or stamped signatures not accepted. Use blue or black ink.

Type Of Enrollment:

New enrollment (new provider, practice location, etc.) Provider re-enrollment

Requesting Enrollment As:

Individual Group Performing Provider

List NPI:

Provider Type:

THSteps Dental

Section A: Provider of Service Information

All applicants, complete the following information.

A.1 Provider Type Specific Information

The applicant (individual, group, or performing provider) must complete the following questions as applicable:

Name of Provider Enrolling (Group/Company Name or Last Name, First Name, Middle Initial):

A.2 Provider Specialty/Taxonomy Information

The applicant (individual, group, or performing provider) must complete the following questions as applicable:

Primary Specialty (select one):

Dentist
Oral & Maxillofacial Surgery
Orthodontia
General Dentistry
Pediatric Dentistry
Orthodontics
Public Health Dentistry
Periodontics
Endodontics
Other

Primary Taxonomy Code:

Sub-Specialty (select one):

If the applicant is a performing provider, complete the following:

Group TPI:

Group Medicare Number:

A.3 Provider Demographic Information

The applicant (individual, facility, group, or performing provider) must complete the following questions as applicable:

Existing Texas Provider Identifiers (TPIs):

Group/Company or DBA Name:

Title/Degree:

Provider business e-mail:

Provider website address:

Telephone number:

Federal Tax ID number:

Physical address fax number:

Accounting/billing address fax number (optional):

Accepting new clients: Yes No

Gender served: Male Female All

Client age restrictions:

Counties served:

Indicate your reason for applying to join the Texas State Health-Care Programs (Select one)

Access to an online application
Adding a new location
Adding performing provider to an existing group
Electronic claims processing
Improved administrative processes
Incentive programs
Learned about Texas State Health-Care Programs at a conference
Learned about Texas State Health-Care Programs at a provider workshop
Recruited by Texas State Health-Care Programs staff
Recruited by TMHP Provider Relations representative
Re-enrolling a provider under an existing provider identifier
Reimbursement increases
Timely reimbursement

Section B: Disclosure of Ownership and Control Interest Statement

This form is required for all individuals, groups, and facilities (exclude performing providers).

B.1 Disclosure of Ownership Instructions

B.2 Disclosure of Ownership Form

I. Identifying information

Legal Name (according to the IRS):

DBA:

Telephone number:

Physical Address:

II. Answer the following questions by checking Yes or No.

Yes No Are there any individuals or organizations having a direct or indirect ownership or control interest of five percent or more ...?

Yes No Does this provider have any current employees in a similar capacity previously employed by carrier/intermediary?

III. Owners, Partners, Officers, Directors, and Principals

Names of individuals with ownership interests of 5 percent or more:

Controlling entities with tax ID:

IV. Ownership

Has there been a change in ownership or control within the last year? Yes No If yes, give date:

V. Management

Does the provider comprise or include a facility operated by a management company or leased by another organization? Yes No

VI. Staffing

Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year? Yes No

VII. Affiliation

Is the provider chain affiliated? Yes No

If yes, provide corporate/home office information:

VIII. Capacity

Have you increased your bed capacity by 10 percent or more or by 10 beds within the last two years? Yes No

IX. Disclosure of Relationship

B.3 Principal Information Form (PIF-2)

Check person or entity:

Person Entity

Tax ID number as shown on the W9 IRS form:

Legal name as shown on the W9 IRS form:

Company Name:

Address as shown on the W9 IRS form:

How is the entity organized to conduct business activities?

Do you conduct business under an assumed name? Yes No

Assumed Name:

If you selected Person above, please complete the following information.

Last Name:

First Name/Middle Initial:

Maiden Name:

List any other alias, name, or form of your name ever used:

Check principal or subcontractor:

Principal Subcontractor

Physical address:

Accounting/billing address:

If your accounting address is different than your physical address, indicate your relationship to the accounting address:

Billing agent Management company Employer Self Other

If you chose Other, please explain:

Social Security Number:

Federal Tax ID number:

Specialty of practice:

Medicare intermediary:

Medicare provider number:

Medicare effective date:

Driver’s license number:

State:

Driver’s license expiration date:

Date of birth:

Gender: Male Female

Do you have one or more professional licenses, accreditations, or certifications?

Yes No

Previous Physical address:

Previous Accounting address:

Your title in the provider organization for which enrollment is being sought:

Your duties to the provider organization:

Section C: Group Practice

This section is only for applicants that are enrolling as a group practice.

Section D: Dental Provider Information Form (PIF-Dental)

Each Provider must complete this Dental Provider Information Form (PIF-Dental), before enrollment.

Last, First, Middle Initial OR Group/Company name:

Maiden name:

National Provider Identifier (NPI):

Primary Taxonomy Code:

Secondary Taxonomy Code:

Non-Texas-enrolled Taxonomy Code:

Physical address:

Accounting/billing address (if applicable):

If your accounting address is different than your physical address, indicate your relationship to the accounting address:

Third Party Biller Management Company Employer Self Other

Supervising Physician License Number and State:

Initial issue date:

Expiration date:

TSBDE Sedation / Anesthesia Permits:

None
Nitrous Oxide/Oxygen Inhalation Conscious Sedation
Level One- Minimal Sedation
Level Two- Moderate Enteral Sedation
Level Three- Moderate Parenteral Sedation
Level Four- Deep Sedation/General Anesthesia

Do you have a Portability Permit Issued by the TSBDE? Yes No

I understand that a copy of my TSBDE Sedation/Anesthesia and/or Portability Permit must be received before my application will be considered complete.

Do you have an Anesthesiology Residency recognized by the American Dental Board of Anesthesiology? Yes No

Do you plan to use a Third Party Biller to submit your health-care claims?

Yes No

Billing agent name:

Address:

Federal Tax ID number:

Contact person name:

Telephone number:

HHSC Medicaid Provider Agreement

Complete the required information at the beginning of the form, read the agreement information, and sign and date the agreement.

Name of provider enrolling:

Medicaid TPI:

Medicare provider ID number:

Physical address:

Accounting/billing address:

Signature Section

Applicant’s Signature:

Appendix A: Additional Forms

The following forms must be attached if applicable:

Corporate Board of Directors Resolution

Electronic Funds Transfer (EFT) Notification

Corporate Board of Directors Resolution

State Of

County Of

Electronic Funds Transfer (EFT) Notification

Type of authorization: New Change

Provider name:

Billing TPI:

NPI/API:

Primary taxonomy code:

Provider accounting address:

Provider phone number:

Bank name:

Bank phone number:

ABA/Transit number:

Account number:

Bank address:

Account type:

Checking Savings

Authorized signature:

Date:

Title:

E-mail address:

Contact name:

Contact phone number:

Appendix B: Important Information - Please Read

The Texas Medicaid Provider Procedures Manual contains important information about provider responsibilities, filing deadlines and procedures, and much more.

For information about Medicaid TPI requirements, the status of your enrollment, or claims submission, call TMHP Contact Center toll-free at 1-800-925-9126.

Filing Deadline Information and Change of Ownership guidance are included in the appendix for reference.

Notary / Resolution Notes: