TX HHS Form 3028. Hemophilia Assistance Program (HAP) Provider Enrollment

The TX HHS Form 3028, Hemophilia Assistance Program (HAP) Provider Enrollment, is a crucial document for healthcare providers seeking to participate in the Texas Hemophilia Assistance Program. This form facilitates the enrollment process by gathering essential information about the provider's facility, business structure, and contact details.

The form requires providers to furnish their National Provider Identifier (NPI), Tax ID number, and primary contact information, including name, phone number, and fax number. Additionally, providers must specify their facility type, such as pharmacy or hospital, and provide physical and business addresses. The form also inquires about the provider's Medicaid participation, including the effective and end dates of coverage.

To facilitate a smooth enrollment process, providers are encouraged to submit a direct deposit form if they plan to receive payments electronically. By completing this form, healthcare providers can ensure timely reimbursement for their services while participating in the Hemophilia Assistance Program. Key points to note include:

• Required information includes facility type, NPI, and primary contact details.
• Providers must specify their business structure and provide physical and business addresses.
• MEDICAID participation information is also required, including effective and end dates of coverage.