Form 6004 "Texas Provider Marketing" - Texas

What Is Form 6004?

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 September 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 6004 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 6004 "Texas Provider Marketing" - Texas

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Form 6004
September 2020-E
Texas Provider Marketing
Provider Marketing Information
Category:
If “other,” explain:
Reading Grade Level of Marketing Material:
Submission for Facility/Group?
Yes
No
Brief Summary of Provider Marketing or Intended Use of Marketing Material:
Has this provider marketing been previously submitted and approved?
Yes
No
If yes, provide approval number:
Provider Marketing County:
Provider Information
Submitter:
If “other,” explain:
Provider Name (Last, First):
National Provider Identifier:
Texas Provider Identifier:
Practice/Facility Name:
Practice Location (City, County, State, ZIP Code):
Email Address:
Home Page URL (if applicable):
I understand that submission of this provider marketing is optional. The applicable sections of the Texas Administrative Code
govern the allowable form, content and use of provider marketing.
HHSC’s provider marketing approval is not extended to any deviations or modifications made to the marketing following the
issuance of HHSC’s approval. This approval does not extend to any future provider marketing.
Form 6004
September 2020-E
Texas Provider Marketing
Provider Marketing Information
Category:
If “other,” explain:
Reading Grade Level of Marketing Material:
Submission for Facility/Group?
Yes
No
Brief Summary of Provider Marketing or Intended Use of Marketing Material:
Has this provider marketing been previously submitted and approved?
Yes
No
If yes, provide approval number:
Provider Marketing County:
Provider Information
Submitter:
If “other,” explain:
Provider Name (Last, First):
National Provider Identifier:
Texas Provider Identifier:
Practice/Facility Name:
Practice Location (City, County, State, ZIP Code):
Email Address:
Home Page URL (if applicable):
I understand that submission of this provider marketing is optional. The applicable sections of the Texas Administrative Code
govern the allowable form, content and use of provider marketing.
HHSC’s provider marketing approval is not extended to any deviations or modifications made to the marketing following the
issuance of HHSC’s approval. This approval does not extend to any future provider marketing.