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Provider Interest Form

Thank you for your interest in joining the Texicare network. Please complete this form and we will review your request and respond within 30 days.

Name

Street Address

City

State

Zip

County

Office Phone

Fax Number

Requestor Name

Requestor Phone

Requestor Email

Provider Specialty(s)

Taxonomy Code(s)

CAQH#

Individual NPI

TIN

Group Name

Group NPI

Bill Type

Hospital Affiliation(s)

Accepting New Patients

Yes No