MED-IT New Provider Request Form42010



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|Instructions for Completing New Provider Request Form for Med-IT: |

|The form must be completed and dated by the BCCS Coordinator. |

|Send completed form(s) to the Med-IThelpdesk@dshs.state.tx.us. Allow 2-3 days for help desk response. |

|Agency Information: |

|Agency Three Digit Number (ex. #035): |Agency Name: |

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|New Provider Information: |

|New Provider Name: | |

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|New Provider Address 1: |New Provider Address 2: |

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|City |County |State |Zip |

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|Facility Type: |

|Contractor      | |

|                | |

|Sub – Contractor | |

|Contact Type: |

|Primary | |

|Contract | |

|Billing | |

|Program | |

|Send Correspondence Yes No |

|Women Above 40 Yes No |

|Service Type : |

|Clinical | |

|Cervical | |

|Breast | |

|Program Coordinator Name: |Date: |

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