VERY IMPORTANT - PLEASE READ THOUROUGHLY!
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.
DME enrollments require additional fees that are paid directly to CMS Medicare and are not included in the TIOPA fees.
We cannot guarentee the enrollment dates to match what is requested.
Providers are responsible for all revalidations at the practice level and if they wish to have TIOPA complete this, it is an additional charge and we cannot guarentee there will not be a lapse in coverage. We are unable to rush applications if the due date is approaching. Applications are completed in the order of reciept. TIOPA is not responsible for keeping track of revalidation due dates.
I authorize that this form has been completed accurately to the best of my ability and understand the terms of this request.