Sample Provider Letter Of Intent (Loi) To Contract (Page 4 of 4) in pdf

Sample Provider Letter Of Intent (Loi) To Contract Page 4

STAR Kids RFP

March 2014

ADDITIONAL PROVIDER AND SERVICES INFORMATION FOR LOI/LOA

BETWEEN PROVIDERS AND RESPONDENTS

FOR PROVISION OF SERVICES TO HHSC HMO MEMBERS

1. HHSC PROVIDER IDENTIFICATION NUMBER, if any

____________________________________________________

2. PROVIDER’S PRINTED NAME

_____________________________________________________

3. ADDRESS (where services will be provided)

______________________________________________________

4. ZIP CODE

_____________________

5. COUNTY

____________________

6. TELEPHONE

__________________

7. FAX

_____________

___ Check here if additional service site information is attached.

8. PROVIDER TYPE (e.g. PCP, OB/GYN, acute care hospital, inpatient mental health facility, Therapy

(PT,OT, ST), etc.)

________________________________________________________________________________

9. SERVICE(S) TO BE PROVIDED TO STAR+PLUS MEMBERS, NOTE ANY DIFFERENCES IN

TYPES OF SERVICE(S) BY PROVIDER SITE.

____________________________________________________________________________

10. AREAS OF PROVIDER SPECIALTY, IF ANY

____________________________________________________________________________

11. LANGUAGES SPOKEN BY THE PROVIDER (OTHER THAN ENGLISH)

_____________________________________________________________________________

12. NAME OF HOSPITAL(S) WHERE PHYSICIAN HAS ADMITTING PRIVILEGES

_____________________________________________________________________________

Sample Provider Letter Of Intent (Loi) To Contract Page 4