MED-IT New Provider Request Form42010
| |
|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: |
| | |
|New Provider Information: |
|New Provider Name: | |
| |
|New Provider Address 1: |New Provider Address 2: |
| | |
|City |County |State |Zip |
| | | | |
|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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