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Once the form is completed you will be sent to our website to pay. Select the options that match the above.

THIS FORM DOES NOT COLLECT PAYMENT!

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Certification of Formation is required for all practices.

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Tiopa can notarize the form.  

Texas Vaccine for Children Program:

Texas Medicaid does not reimburse for vaccines available for the TVFC program. 

Provider Required Questions

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I hereby give TIOPA, Inc. permission to access the accounts listed above and complete the submission for enrollment. I understand that all enrollment times vary and are at the discretion of CMS Medicare and TMHP Medicaid.

I understand that I must FIRST grant access to TIOPA in order to begin the process and no applications can or will be submitted until connection requests are completed. 

I understand that if this form is completed incorrectly or with omitting information, this will cause delays in enrollment cause approval time to take longer. I understand that it is solely the provider's responsibility to provide all information accurately and promptly for submissions to take place.

I understand that if requested items are not received within 90 days or after three requests that my extra services request with TIOPA will be suspended and no longer queued a priority, and can be canceled if the on-hold application remains stagnant. 

I understand that submission of enrollment does not guarantee approval or participation.

I understand that I or my office staff are responsible for letting TIOPA know via email to provider.relations@tiopa.org of any address changes and understand that an additional change fee is required, if not completed by myself or the office staff. 

I understand that any change of information (ie Demographic Update) are NOT covered and must be specifically requested and an additional fee of $75-$500 is required per change. 

Physical Therapy Practices could be required to pay an additional $631 to Texas Medicaid Health Partnership (TMHP) directly, as it is considered an "institutional-based" practice. 

I authorize that this form has been completed accurately to the best of my ability.