Form 1090 "Oral Evaluation and Fluoride Varnish Certification Application" - Texas

What Is Form 1090?

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 1090 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form 1090 "Oral Evaluation and Fluoride Varnish Certification Application" - Texas

405 times
Rate (4.6 / 5) 20 votes
Form 1090
August 2020-E
Texas Health Steps
Oral Evaluation and Fluoride Varnish Certification Application
Performing Provider Name:
Check appropriate box:
Private Practice
Group Practice
Federally Qualified Health Center
Rural Health Center
Name of Group/Facility:
Check appropriate box:
Primary Care Physician
Physician Assistant
Advanced Practice Nurse
Taxonomy Code:
Group Tax ID:
Provide the following required information:
Individual National Provider Identifier (NPI) No.:
Group NPI No.:
Do you have a personal Texas Health Steps (THSteps) Texas Provider Identifier (TPI) number)?
Yes
No
If yes, enter THSteps personal TPI No.:
Group THSteps TPI No. (Used to bill Medicaid):
I am currently enrolled as a THSteps Primary Care Provider
I have submitted an application as of [Date of submission]
Physical Address (Street, Suite):
City:
ZIP Code:
Area Code and Phone No.:
Office Contact (person who can answer questions):
Email Address (where verification should be sent):
Date Training Completed:
Email this completed form and 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 1090
August 2020-E
Texas Health Steps
Oral Evaluation and Fluoride Varnish Certification Application
Performing Provider Name:
Check appropriate box:
Private Practice
Group Practice
Federally Qualified Health Center
Rural Health Center
Name of Group/Facility:
Check appropriate box:
Primary Care Physician
Physician Assistant
Advanced Practice Nurse
Taxonomy Code:
Group Tax ID:
Provide the following required information:
Individual National Provider Identifier (NPI) No.:
Group NPI No.:
Do you have a personal Texas Health Steps (THSteps) Texas Provider Identifier (TPI) number)?
Yes
No
If yes, enter THSteps personal TPI No.:
Group THSteps TPI No. (Used to bill Medicaid):
I am currently enrolled as a THSteps Primary Care Provider
I have submitted an application as of [Date of submission]
Physical Address (Street, Suite):
City:
ZIP Code:
Area Code and Phone No.:
Office Contact (person who can answer questions):
Email Address (where verification should be sent):
Date Training Completed:
Email this completed form and 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.