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