Form 1091 "First Dental Home Certification Application" - Texas

What Is Form 1091?

This is a legal form that was released by the Texas Health and Human Services - a government authority operating within Texas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2020;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 1091 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 1091 "First Dental Home Certification Application" - Texas

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Form 1091
August 2020-E
Texas Health Steps
First Dental Home Certification Application
Dentist’s Name:
Check appropriate box:
Pediatric Dentist
General Dentist
Taxonomy Code:
Texas Dental License No.:
Check appropriate box:
Private Practice
Federally Qualified Health Center (FQHC)
Rural Health Clinic
Individual National Provider Identifier (NPI) No.:
Individual Texas Provider Identifier (TPI) No.:
FQHC Only: Group TPI No. (if applicable):
Office Contact Person:
Email Address (where confirmation should be sent):
I am a currently enrolled Texas Health Steps Dental Provider
I have submitted an enrollment application as of [Date of submission]
Physical Office Address:
City:
ZIP Code:
Area Code and Phone No.:
Office Tax ID No.:
Training Date:
Email this completed form and a copy of your CE certificate to: THStepsOEFV.FDH@hhsc.state.tx.us; or fax completed
form and your CE certificate to 512-483-3979.
If you have questions, contact Louise Friedman by phone at 512-776-2110.
Form 1091
August 2020-E
Texas Health Steps
First Dental Home Certification Application
Dentist’s Name:
Check appropriate box:
Pediatric Dentist
General Dentist
Taxonomy Code:
Texas Dental License No.:
Check appropriate box:
Private Practice
Federally Qualified Health Center (FQHC)
Rural Health Clinic
Individual National Provider Identifier (NPI) No.:
Individual Texas Provider Identifier (TPI) No.:
FQHC Only: Group TPI No. (if applicable):
Office Contact Person:
Email Address (where confirmation should be sent):
I am a currently enrolled Texas Health Steps Dental Provider
I have submitted an enrollment application as of [Date of submission]
Physical Office Address:
City:
ZIP Code:
Area Code and Phone No.:
Office Tax ID No.:
Training Date:
Email this completed form and a copy of your CE certificate to: THStepsOEFV.FDH@hhsc.state.tx.us; or fax completed
form and your CE certificate to 512-483-3979.
If you have questions, contact Louise Friedman by phone at 512-776-2110.