DRISCOLL HEALTH PLAN
To contract with Driscoll Health Plan, please complete the following form and fax to: (361) 653‐7850. Upon receipt of
completed form, the Contracting Department will draft a contract and make available to you via e‐mail or fax for your review
and signature along with additional instructions. You may add additional pages to provide all other places of service. DHP
looks forward to working with you!
Request for Contract
Date of Request:_________ Requested by:__________________ Title:____________________
Requestor’s Phone No. _________________Email:___________________________________
MAIN PROVIDER INFORMATION
Provider Name:_________________________ Group Name:____________________________
Tax ID:_________________________ Group NPI: ______________Group TPI:______________
Specialty:_______________________ Taxonomy:____________________________________
Individual TPI: ________________Individual NPI:________________ S.S. No._______________
CAQH No:___________________
Physical Address (POS):
Billing Address:
Primary Place of Service, (POS)
(Must be a Physical Address) (Different
from Billing Co.)
______________________________________
______________________________________
______________________________________
______________________________________
City, _______________State _____Zip_______
City, _______________State ______Zip______
Phone: ________________________________
Phone:________________________________
Fax:___________________________________
Fax:___________________________________
Mailing Address:
Pay To Address:
_______________________________________
______________________________________
_______________________________________
______________________________________
City, _______________State _____Zip_______
City, _______________State ______Zip_______
Phone: ________________________________
Phone:_________________________________
Fax:___________________________________
Fax:____________________________________
FOR OFFICE USE ONLY
W‐9
Credentialing Rep:
Texas License and Liability Insurance
Credentialing Date:
TMHP Attestation
Type Contract:
Credentialing Application
Ancillary Group Individual IPA PHO RHC
CAQH
FQHC
New Provider Check List
Other: ______________________________
EFT
Providers please Note: The credentialing process ranges from 60 to 90 days. In some instances it may take up to 180 days.
Form #: DHP160
10/2012