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For Providers Provider Account Management

Modify Existing Contract

Thank you for your interest in becoming a Scott and White Health Plan contracted provider.

Please complete this form if you would like to amend your current SWHP contract.

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

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* Provider Name:
* TIN or SSN:
* NPI Number:
* TPI Number:
* Medicare Number:
* Phone Number:
Ext:
* Fax Number:
* Email or Website:
* Contact Name:
* Contact Phone:
* Contact Fax:
* Contact Email:
Please provide a detailed explanation, in the comment section below,
regarding the modifications you would like to make to your current SWHP contract:
Comments/Notes:
Attach File
(PDF or ZIP Only)
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Thank you again for your interest in becoming a Scott and White Health Plan contracted provider.

Please allow 30-45 days before checking on status.

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Please download, fill out, and email the SWHP New Provider Contract Form to ensure timely handling of your request.

Thank you again for your interest in becoming a Scott and White Health Plan contracted provider.

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