Form Dhp160 - Request For Contract Form - Driscoll Health Plan printable pdf download

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:___________________________________

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

Form Dhp160 - Request For Contract Form - Driscoll Health Plan

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