Rate Enhancement Affidavit
The individuals whose signatures are set forth below represent and warrant that they are duly empowered to execute this affidavit. Affiant represents and warrants that it has all legal authority to respond on behalf of and to bind the Participating Provider to the terms of the Affidavit. A material or false statement or omission made in connection with this affidavit may subject the person and/or entity making the false statement to any and all criminal penalties available pursuant to applicable Federal and Texas state law.
Participating Provider: A provider who is contracted with Superior HealthPlan.
Rate Enhancement: An additional amount of monies paid to a provider to be passed on for compensation of direct care staff.
Only participating providers who are enrolled in the State of Texas Medicaid Program are eligible to participate in Superior HealthPlan’s Rate Enhancement Program.
Please Note: For your records, a copy of this submission will be sent to the affiant's email address provided above.
Please complete and mail in your form per instructions, no later than October 30, 2019.