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.

 
 
mm/dd/yyyy
 

ENTITY BILLING INFORMATION

 

Line 1 of W9

 

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

 

i.e. 12-3456789

 

10 digits.

 

Select One

 

ENTITY DATA

 

Select One

 
 
 

Select One

 

Enter N/A if not applicable.

 

Enter N/A if not applicable.

 

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

 
 

PRIMARY PRACTICE DEMOGRAPHICS

 

List all that apply.

 

Enter N/A if not applicable

 
 

TX

 
 
 
Phone
 
Phone
 

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

 
 

CONTACT INFORMATION

 

John Smith / Office Manager

 
Phone
 
 

Dr. Smith / Owner

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

 
Phone
 
 

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