Texas Medicaid Provider Contract Request Form

Medical Provider Type *

Group Individual

Provider Type *

Primary Care Physician Medical Specialist Behavioral Health Specialist Primary Care Physician & Specialist Ancillary

Do you provide Targeted Case Management/Mental Health Rehabilitative Services? *

Yes No

Are you Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Accredited? *

Yes No

Request Network Participation, Non-Contracted Providers Only