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Waiver Payment Forms for UC/DSRIP Providers

Contacts

Note: Rate Analysis staff can assist you with questions concerning only payment rates for the specified services. They are not able to answer other types of questions, such as the status of payment for services rendered or questions involving eligibility for care services.

If you have questions regarding the completing of these forms, please call the appropriate person on the Contacts List.

For information public and private provider classification view the Section VIII Addendums.

Forms to be completed by Eligible UC/DSRIP Providers:

*Entity Name, Address, Phone Number, etc. must match on both the Application for Texas Identification Number and the Direct Deposit Authorization/Advance Payment forms.

Forms to be completed by Governmental Entity:

*Entity Name, Address, Phone Number, etc. must match on both the Application for Texas Identification Number and the Direct Deposit Authorization/Advance Payment forms

View the New Affiliations or Providers Checklist for Packet Submission

These checklists identify the documents that need to be submitted by private hospitals submitting TXHUC forms and physicians submitting TXPUC forms.

Access the UC Tool

Contact Rate Analysis

Send email to Rate Analysis


Updated: September 26, 2013