TX HHS Form 3109. Provider Information Change

The TX HHS Form 3109, Provider Information Change, is a crucial document for healthcare providers to update their information with the Texas Health and Human Services (HHS) department. This form helps solve the problem of outdated provider information on file with HHSC, ensuring that accurate contact details are maintained.

This form requires essential information such as primary taxonomy code, name and title of staff requesting the change, address modifications, communication preferences, tax information, and a change effective date. Providers can use this form to modify their physical or accounting addresses, add an alternate address, delete an existing alternate address, or report changes in provider status.

The form also includes sections for reporting legal name changes, TIN updates, and closure of provider services (CCHOW) or voluntary disenrollment. A required signature from the authorized provider is necessary to complete the form. Providers can submit completed forms electronically, by fax, or by mail to Provider Relations at [email protected], 512-776-7238, or P.O. Box 149030, Austin, TX 78714-9947.