F00092 Page 1 of 2 Revised: 02/15/2023 | Effective: 02/15/2023
State of Texas Medicaid Provider Surety Bond
e State of Texas Medicaid Provider Surety Bond form must be completed by the surety company and signed by an authorized power of
attorney of the surety company and an authorized representative of the Texas Medicaid provider. is is the only acceptable form for the
submission of a surety bond in compliance with the Title 1 Texas Administrative Code (TAC) §352.15. e use of this form designates
the Texas Health and Human Services Commission (HHSC) as the sole obligee of the bond. Surety bonds that are obtained for the
purpose of accreditation in the Medicare program and list the Centers of Medicare & Medicaid Services (CMS) as obligee will not fulll
the surety bond requirement for Texas Medicaid.
Important: Submit the completed bond form with a copy of the Power of Attorney document from the issuing surety company.
Complete the State of Texas Medicaid Provider Surety Bond form as follows:
Item Instructions
National Provider Identier
(NPI) or Tax ID
Enter the National Provider Identier (NPI) or the tax identication number (Tax ID).
Bond Number Enter the bond number as determined by the surety company.
Provider’s Name Enter the provider’s/applicant’s legal name according to the Internal Revenue Service (IRS).
d/b/a Enter the provider’s/applicant’s “doing business as” name.
Provider’s Physical Address Enter the physical address of the provider’s/applicant’s practice location.
City of Enter the city of the provider’s/applicant’s physical address.
County of Enter the county of the provider’s/applicant’s physical address.
State of Enter the state of the provider’s/applicant’s physical address.
Surety Name Enter the name of the surety company that is issuing the bond.
State of Enter the state in which the surety company is incorporated.
Surety Address Enter the business address of the issuing surety company.
City of Enter the city of the surety company’s business address.
County of Enter the county of the surety company’s business address.
State of Enter the state of the surety company’s business address.
Total Amount of
Enter the total amount of the bond, which must be equal to at least $50,000 per location. If the bond
will cover more than one enrolled location, attach a list of all locations on a separate page.
is Bond is eective
Enter the date that the bond coverage begins. e surety bond submitted must be a continuous
bond and for a term of 12 months. e bond must be in eect at the time that the provider
enrollment application is submitted.
Signed and dated Enter the date that the surety bond is signed and executed by both parties.
Authorized Representative Enter the printed name of the authorized representative who is signing the bond.
Title Enter the business title of the authorized representative of the Texas Medicaid provider/applicant.
Authorized Power of Attorney
Enter the printed name of the authorized power of attorney of the surety company that is signing
the bond.
Authorized Power of Attorney
Signature
is line is for the signature of the authorized power of attorney of the surety company.
Bond will cover more than one
location
Attach a list of all locations to be covered under this bond. e list must include the d/b/a, physical
address, and NPI for all locations covered.
Proof of Continuation: Upon renewal of the bond every 12 months, proof of continuation must be submitted to the Texas
Medicaid & Healthcare Partnership (TMHP) on the surety bond company’s form and must include specic information. is State of
Texas Medicaid Provider Surety Bond form must not be used to submit proof of continuation. Providers can refer to the Texas Medicaid
Provider Procedures Manual for the proof of continuation requirements.
F00092 Page 2 of 2 Revised: 02/15/2023 | Effective: 02/15/2023
State of Texas Medicaid Provider Surety Bond
NPI or Tax ID: Bond Number:
Know all persons by these presents that subject to the terms, conditions, and limitations of this bond,
d/b/a
with its place of business at
City of , County of , State of , as principal,
And , a corporation organized and existing under the laws of the
State of , with its principal place of business at City of ,
County of , State of and authorized to transact a surety business in the State of Texas, as
surety, are held and rmly bound unto the Health and Human Services Commission (HHSC), an agency of the State of Texas, as
obligee in the penal sum of Fiy ousand Dollars ($50,000) for each enrolled location for a total amount of ,
for which payment principal and surety bind themselves, their heirs, executors, administrators, successors and assignee, jointly and
severally. (If bond will cover more than one enrolled location, attach a list of all locations on a separate page.)
WHEREAS, Principal is enrolled in or seeking to be enrolled in the Texas Medicaid program as a provider.
WHEREAS, pursuant to Title 1 Texas Administrative Code (TAC) §352.15, the Principal is required to provide a surety bond as a
condition of participation in the Medicaid program, and this bond is provided in compliance with the provider’s obligations as set forth
in this authority.
NOW THEREFORE, the condition of this Bond is that if the Principal shall pay the Obligee any uncollected overpayments (as this term
is dened by Title 42 Code of Federal Regulations (CFR) §433.304), then the Bond shall be null and void, otherwise to remain in full
force and eect, subject, however, to the following:
1. Principal and Surety are liable under this Bond for only the amount of any uncollected overpayments for which the Principal is
responsible and for which subject to Paragraph 8, are determined during the term of the bond.
2. Surety agrees to pay a claim within 30 days of receiving written notice of the claim and sucient evidence to establish Surety’s
liability under this Bond.
3. HHSC is the sole Obligee of this Bond, and no action may be brought on it by, or for the use or benet of, any person or entity
other than HHSC, its contractors, or designated agent.
4. Regardless of the number of years this Bond is in eect, the number of premiums paid, or the number of claims made, the Surety’s
aggregate liability shall not be more than the penal sum of this Bond.
5. e Surety’s liability under this Bond shall not be aected, diminished, or concluded by any action by the Principal or the Surety to
terminate, reduce, or limit the scope or term of the bond; by any action by the Principal to cease operation, sell or transfer any assets
or ownership interest, le for bankruptcy, or fail to pay the Surety; or by the Principal’s failure to exercise available appeal rights
under Medicaid or CHIP.
6. Subject to Paragraph 8, the Surety’s liability under this Bond shall terminate and the Surety shall have no further liability upon the
eective date of cancellation or expiration of this Bond by the Surety or Principal in accordance with Paragraph 7 of this Bond.
7. e Surety or Principal may cancel this Bond by providing written notice of such cancellation to the Obligee. Cancellation or
expiration shall be eective 30 days aer notice of cancellation is sent to the Obligee’s contractor provided such notice is actually
received.
8. In the event the Principal’s participation in the Medicaid program is terminated or this Bond is cancelled or expires, and the
Principal fails to submit a new bond to the Obligee, the Surety remains liable for uncollected overpayments that occurred during the
term of the bond for 2 years following the eective date of cancellation or expiration of this Bond.
is Bond is eective . Signed and dated this day of , 20 .
Provider’s Name: Surety Name:
Authorized Representative: Authorized Power of Attorney:
Signature: Signature:
Title:
(Provider’s Name)
(Provider’s Physical Address)
(Surety Name)
(Surety Address)
