Provider Information
Please enter the requested information below.
Type of Visit:
Provider Education
Recruitment
Outreach
Please select the type of visit performed.
Provider Name:
First Name
Last Name
Provider TPI:
Provider Type:
Provider NPI:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Provider E-mail:
example@example.com
Phone Number:
-
Area Code
Phone Number
Representative Information
Please enter the requested information below.
Representative:
First Name
Last Name
Representative E-mail:
example@example.com
Territory:
Travel time (hrs., min.):
Visit time (hrs., min.):
Number of providers impacted:
Program(s) impacted / discussed (check all that apply):
Traditional/FFS
CSHCN
THSteps Medical
THSteps Dental
Long Term Care
Healthy Texas Women
Other
Issues Discussed
Please enter the requested information below.
Technology:
TMHP.com
PA on the Portal
TexMedConnect
Online Provider Lookup
Provider Enrollment on the Portal
Other
Issue:
Authorization
Billing Education
EDI/EHR/TMC
Eligibility Education
Enrollment/Re-enrollment/ACA
Finance
Fraud and Abuse
MCO
TMAS/Referral
TMPPM Education
Other
Outreach:
DSHS Meeting
Association Event
HHSC Meeting
Other
Materials Provided:
Medicaid QRG
THSteps QRG
Other
New Enrollment:
Yes
No
PEP ID:
Enter PEP ID
Visit Requires Follow Up / Additional Research:
Yes
No
Date of follow-up:
-
Month
-
Day
Year
Select a Date Above
Comments:
Representative must sign here:
*
Date Signed:
-
Month
-
Day
Year
Select a Date Above
Provider must sign here:
*
Date Signed:
-
Month
-
Day
Year
Select a Date Above
Upload attachments (if applicable):
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