Network Interest Form

Network Interest Form

Thank you for your interest in joining the Texicare network. To be considered, please complete and submit this form.

It should be filled out at the practice level and not for any individual practitioners billing under the contracting entity unless the practitioner is a solo provider. We will review your submission and respond within 30 days.

If you have any questions, please email providercontracting@texicare.com.

Today's Date

ENTITY BILLING INFORMATION

Legal Group Name:*

Line 1 of W9

Doing Business As Name:*

Line 2 of W9. Enter N/A if not applicable.

EIN/TIN:*

i.e. 12-3456789

Organization NPI:*

10 digits.

Bill Type:*

Select One

Select

ENTITY DATA

Practice Type:*

Select One

Select or enter value

Primary Specialty:*

Patient Types:

Select

Accepting New Patients:*

Select One

Select or enter value

# of Physicians:*

Enter N/A if not applicable.

# of Mid-Levels:*

Enter N/A if not applicable.

Hospital Affiliations:*

List of Hospitals with Provider Privileges. Enter N/A if not applicable.

PRIMARY PRACTICE DEMOGRAPHICS

Practice Address:*

List all that apply.

Practice Address:*

Enter N/A if not applicable

City:*

State Initials:

Zip:*

Counties:*

Office Phone Number:*

Phone

Office Fax Number:*

Phone

Public Email for Patient Inquiries:*

An electronic communication method, like a group inbox, is required for patients and should be listed on your website.

Website:*

CONTACT INFORMATION

Requestor's Full Name / Title:*

John Smith / Office Manager

Requestor's Phone Number:*

Phone

Requestor's Email:*

Contract Practice Contact Full Name / Title:*

Dr. Smith / Owner

Enter Same as above or N/A if not applicable.

Contract Practice Contact Phone Number:*

Phone

Contract Practice Contact Email:*

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