TX HHS Form 5201. Med-IT New Provider Request

The TX HHS Form 5201, Med-IT New Provider Request, is a crucial document for healthcare providers seeking to join the Breast and Cervical Cancer Services (BCCS) program. This form must be completed and dated by the BCCS Program Coordinator, allowing three business days for Help Desk response.

The form consists of five sections: Agency Information, New Provider Information, BCCS Program Primary Contact Information, New BCCS Provider O Clinic Site or Subrecipient information, and Signature. Key features include the requirement to provide certification or license number and expiration date, as well as the type(s) of services the new provider will perform. The form also highlights the importance of contacting the Med-IT Help Desk for any issues or concerns.

This form should be used by healthcare providers seeking to join the BCCS program or by existing providers who need to update their information. It is essential to complete this form accurately and submit it by email as instructed. If no response is received after three business days, providers can contact [email protected] for assistance.