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 to initiate their partnership with the Breast and Cervical Cancer Services (BCCS) program. This form helps solve the problem of new providers joining the BCCS network by providing essential information about their agency, services, and primary contact details.

The form requires key information from the new provider, including agency region number, certification or license number, expiration date, and type of services they will perform (clinical, cervical, or breast). The form also outlines responsibilities for the BCCS Program Coordinator to complete and date the form, with a response time frame of three business days. If no response is received after this timeframe, providers can contact [email protected].

Key features of the form include the need for new providers to certify their agency information, specify the type of services they will perform, and provide primary contact details. The form also emphasizes the importance of follow-up actions, such as contacting the BCCS Program Coordinator if no response is received within three business days. By submitting this form, new providers can ensure a smooth onboarding process with the BCCS program.

• The form is used by healthcare providers to initiate their partnership with the Breast and Cervical Cancer Services (BCCS) program.
• New providers must complete and date the form within three business days, with a follow-up response expected from the BCCS Program Coordinator.
• The form requires key information about the new provider's agency, services, and primary contact details.