Waiver Payment Forms for UC/DSRIP Providers

For information regarding 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 (.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)

*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)

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

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/DSRIP Providers (.pdf)

View the Physician Providers (.pdf)

View the 2021 DSH/UC Application Webinar

View the 2021 DSH/UC Application Webinar (.wmv)