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 (512) 491-1862.
For information public and private provider classification view the Section VIII Addendums.
Forms to be completed by Eligible UC/DSRIP Providers:
- View the Certification of Hospital Participation
- View the Certification of Physicians Group Participation
- View the AP - 152 (application for Texas Identification Number) *
- View the 74 - 176 (Direct Deposit Authorization/Advance Payment Notification) *
- View the 74 - 193 Advance Payment Notification Form (for hospitals who already have Direct Deposit)
*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:
- View the Certification of Governmental Entity Participation
- View the Certification of Governmental Entity Participation (for Physician Affiliates)
- View the AP - 152 (Application for Texas Identification Number) *
- View the 74 - 176 (Direct Deposit Authorization/Advance Payment Notification) *
- View the 89 - 103 TexNet Enrollment Form
*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.
- View the UC/DRSIP Providers
- View the Physician Providers
Access the UC Tool
- Access the DSH and Non-DSH UC Tool
- Access the Physician UC Tool
Contact Rate Analysis
Updated: September 25, 2012