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) agency. This form helps resolve issues related to changes in provider information, ensuring accurate records and efficient communication.

This form is typically used by healthcare providers who need to modify or update their information with HHS, such as changing their physical address, adding an alternate mailing address, or updating their tax information. The form requires the provider's primary taxonomy code, name and title of staff making the request, and current and new addresses on file with HHSC.

To complete this form, providers must provide required information, including their legal name, taxpayer identification number (TIN), and communication preference. They must also indicate the reason for the change, which may include a closure or voluntary disenrollment from the Hemophilia Assistance Program (HAP) Services. The form must be submitted electronically to [email protected], by fax to 512-776-7238, or by mail to Provider Relations at P.O. Box 149030, Austin, TX 78714-9947.

• This form is used for updating provider information with HHS.
• Required information includes primary taxonomy code, name and title of staff making the request, and current and new addresses on file with HHSC.
• The form must be submitted electronically or by mail to Provider Relations.