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For Providers Provider Account Management

Add Provider to Contract/Group Form

Please complete this form to add a provider to your existing contract with SWHP.
Submission of this form is not an automatic approval to SWHP’s network.
We will contact you for more information or confirmation of your request.

Please complete all fields. Enter N/A if a field is not applicable.

* Indicates required information

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Please enter values for all of the fields in the color of this box below.
Once done, click the "Submit" button again.
* Group Name:
* Group NPI:
* Provider Name:
(as shown on W9)
* Joined Group Date:
* Specialty:
* Provider Type:
* Board Certified:
* Tax ID:
* NPI:
* TPI Medicaid:
* Medicare:
* Phone Number:
* FAX Number:
* Email or Website:
* Contact Name:
* Contact Email:
* Contact Position/Title:
* Contact Phone:
Contact Extension
* Contact FAX
Comments/Notes
Attach File
(PDF or ZIP Only)
* Tells us what you think?

Success!

Thank you again for your request to add a provider to your Scott and White Health Plan contracted group.

Please allow 30-45 days before checking on status.

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