Provider Data Upload - Texas Independence Health Plan

Medicare Payment Plan Eligibility

Name(Required)

First Middle Last

Medicare Number(Required)

Birth Date(Required)

Phone(Required)

Email(Required)

Permanent Residence Street Address(Required)

Street Address Address Line 2 City State ZIP Code

Don't enter a P.O. Box unless you're experiencing homelessness.

Mailing Address (if different from your permanent address)

Street Address Address Line 2 City State ZIP Code

P.O. Box allowed

Request A Profile

Name(Required)

First Last

Email(Required)

Health Plan Member ID(Required)

The Health Plan Member ID is shown on the member ID card.

Gender(Required)

Phone Number(Required)

Birth Date(Required)

Texas Independence Health Plan Documents

"*" indicates required fields

Protected: Provider Data Upload