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For Providers Provider Account Management

New Provider Contract Form

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

Please complete this online application form to begin the process for inclusion in our network.

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

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* Provider Type:
* Provider Name:
(as shown on W9)
* Specialty:
* PCP or Specialist:
* Tax ID:
* NPI:
* Group NPI:
* TPI Medicaid:
* Medicare:
* Board Certified:
* Per Occurrence:
(Malpractice Insurance Limit)
$
* Aggregate:
(Malpractice Insurance Limit)
$
* Street Address:
* City:
* State:
(abbreviation)
* Zip Code:
* County:
* Phone Number:
* FAX Number:
* Email or Website:
* Contact Name:
* Contact Position/Title:
* Contact Phone:
Contact Extension
* Contact FAX
* Contact Email:
* Laboratory
* Radiology
* Pharmacy
* Hospital Admissions/Privileges
* Emergency Room
Comments/Notes
* Attach W-9
(PDF Only)
* Tells us what you think?

Success!

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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