Texas Health and Human Services
Each Enrollment Application Must Contain the Following Items.NOTE: Applicant must submit a separate and complete enrollment application and required documents for each clinic site.DocumentCheck (√), if includedFORM A: Face Page – Signature RequiredFORM B: Open Enrollment Application ChecklistFORM C: Contact Person Information FormFORM D: Applicant Readiness (provide items listed below)Clinic Site/License InformationDATA 2000 Waiver for each prescribing Physician, prescribing Nurse Practitioner, and prescribing Physician Assistant under this Open EnrollmentProof of DEA Special Identification Number for each prescribing Physician, prescribing Nurse Practitioner, and prescribing Physician Assistant under this Open EnrollmentProof of DEA Regular Registration Number for each prescribing Physician, prescribing Nurse Practitioner, and prescribing Physician Assistant under this Open EnrollmentCopy of Memorandum of Understanding for each prescribing Physician, prescribing Nurse Practitioner, Physician Assistant under this Open EnrollmentCopy of written agreement with a PharmacyCopy of applicant’s organization chartTexas Medicaid and Healthcare Partnership Information – Texas Provider Identifier (TPI) numberMedicaid Information – National Provider Identifier (NPI) numberCertificate of InsuranceInformation Security and Privacy Initial Inquiry (SPI) Form ................
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