PDF
Word
This version of the form is not currently in use and is provided for reference only. Download this version of
Form 3109
for the current year.
Form 3109 Provider Information Change - Texas
What Is Form 3109?
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.
FAQ
Q: What is Form 3109?A: Form 3109 is the Provider Information Change form specific to Texas.
Q: Who can use Form 3109?A: Form 3109 can be used by healthcare providers in Texas who need to update their information.
Q: What type of information can be changed using Form 3109?A: Form 3109 can be used to update provider's personal information such as address, phone number, and contact information.
Q: Is there a fee to submit Form 3109?A: No, there is no fee associated with submitting Form 3109.
Q: How should I submit Form 3109?A: Form 3109 can be submitted by mail or fax, as specified on the form and instructions provided.
Q: How long does it take to process Form 3109?A: The processing time for Form 3109 may vary, but typically it takes a few weeks to update the provider's information.
Q: What happens after submitting Form 3109?A: After submitting Form 3109, the provider's information will be updated in the Texas provider database, and any future correspondence will reflect the new information.
Q: Can I use Form 3109 to change my provider type or specialty?A: No, Form 3109 is only for updating personal information. Changes in provider type or specialty may require a different form or process.
Form Details:
- Released on January 1, 2021;
- 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 3109 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.
