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 crucial document for healthcare providers to attest that they did not collect office visit co-pays from CHIP members during specified dates of service. This form helps resolve the issue of uncollected co-payments by providing a formal declaration of non-collection.

The form requires the provider to certify that the attached invoices represent office visit co-pays that were not collected for CHIP members, as directed by the Texas Health and Human Services Commission. The provider must also sign and date the document, acknowledging their understanding that false or untrue information may result in penalties. Additionally, all original documents will be retained and preserved as required by law.

This form is typically used by healthcare providers who have not collected office visit co-pays from CHIP members during specific dates of service. Key requirements include providing accurate information about the invoices and dates of service, and understanding the potential consequences of providing false or untrue information. By using this form, providers can ensure compliance with regulations and maintain accurate records.

• The form is used to attest that office visit co-pays were not collected from CHIP members during specified dates of service.
• The provider must sign and date the document, acknowledging their understanding of potential penalties for false or untrue information.
• Original documents will be retained and preserved as required by law.