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NETWORK PROVIDER UPDATE FORM (PUF)
MEDICAID

Effective
Date

IPA
Affiliation

 

THIS FORM MAY BE REPLACED BY AN IPA PROFILE WITH THE
APPROPRIATE INFORMATION INCLUDED

Please PRINT all information. If information has changed please mark the box on the right.

 

PROVIDER'S NEW INFORMATION

NAME: First/MI/Last/Degree:

,

Practice Name/Group:

Primary Specialty:

Secondary Specialty:

IPA:

Address 1:

City/State/ZIP/County:

Address 2:

City/State/ZIP/County:

Phone #:

Fax #:

After Hours Phone #:

Billing Address:

Federal Tax ID #:

City/State/ZIP/County:

 

 

TPI(s) #:

Group(s) #:

Texas License #:

Office Manager #:

Contact #:

Please mark the appropriate response.

Type of Practice:
Group
Solo
Accepting New Patients:
Yes
No
      If No, estimated date to re-open:
 
Practice Limitations:     Specialty Type Limitation:
 
    Age Limitations:
 

Office Hours

MON.

TUE.

WED.

THU.

FRI.

SAT.

SUN.

Primary Admitting Hospital(s):

Ethnic Origin:
White
American Indian/Alaskan
 
Black
Hispanic
 
Asian
American Woman
 
Other/Unknown
 
Are you a Certified Historically Underutilized Business (HUB)?
Yes
No

If Yes, enter HUB number:
 

Language(s) Spoken Fluently:
Spanish
Other(s):
 
Provider Gender:
Male
Female
 
 
Public Transit:
Yes
No
 
 
Handicap Access:
Yes
No
 
 
Do You File Claims Electronically:
Yes
No

If Yes, enter your clearinghouse:
 
Are You Interested In Electronic Funds Transfer:
Yes
No
 
 
THSteps:
Yes
No

If Yes, enter number: