Waiver Payment Forms for UC/DSRIP Providers

For information regarding public and private provider classification view the Section VIII Addendums (.pdf).

Forms to be completed by Eligible UC/DSRIP Providers:

View the Certification of Hospital Participation (.pdf)

View the Certification of Physicians Group Participation (.pdf)

View the Certification of Private Physician Participation (.pdf)

View the AP - 152 (application for Texas Identification Number) * (.pdf)

View the 74 - 176 (Direct Deposit Authorization/Advance Payment Notification) * (.pdf) Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this 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.

Forms to be completed by Governmental Entity:

View the Certification of Governmental Entity Participation (.pdf)

View the Certification of Governmental Entity Participation (for Physician Affiliates) (.pdf)

View the Certification of Governmental Entity Participation Private Physician Affiliates (.pdf)

View the AP - 152 (application for Texas Identification Number) * (.pdf)

View the 74 - 176 (Direct Deposit Authorization/Advance Payment Notification) * (.pdf) Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.

View the TexNet Enrollment Page

View the TexNet User Guide (.pdf)

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