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Form 5004 Optional Covid-19 Chip Provider Co-payment Attestation - Texas
What Is Form 5004?
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 5004?
A: Form 5004 is an Optional Covid-19 Chip Provider Co-payment Attestation form in Texas.
Q: What is the purpose of Form 5004?
A: The purpose of Form 5004 is to attest that a chip provider in Texas is waiving any co-payment for COVID-19 testing and related services.
Q: Who needs to complete Form 5004?
A: Chip providers in Texas who are waiving co-payments for COVID-19 testing and related services need to complete this form.
Q: Is Form 5004 mandatory?
A: No, Form 5004 is optional for chip providers in Texas.
Form Details:
- Released on May 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 5004 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.
