TX HHS Form 5004. Optional COVID-19 CHIP Provider Co-payment Attestation

The TX HHS Form 5004, "Optional COVID-19 CHIP Provider Co-payment Attestation", is a document used by healthcare providers to certify that they did not collect office visit co-pays from CHIP members for specific dates of service. This form helps resolve the issue of uncollected co-payments and ensures compliance with direction from Texas Health and Human Services Commission.

The form requires the provider to attest that the attached invoice amounts represent office visit co-pays that were not collected for a specified period, in accordance with commission direction. The provider must also certify that the information provided is true and correct to the best of their knowledge and belief, noting that providing false or untrue information may result in penalties.

This form should be used by healthcare providers who have uncollected office visit co-pays from CHIP members for specific dates of service. The form's instructions note that all original documents will be retained and preserved as required by law, and submitted or access permitted as required by HHSC or other government agencies. The provider must ensure that the dates of service on the claims being submitted to the managed care organization cover the same period.