Add Provider to Contract/Group Form

Complete this form to add a provider to your existing contract with Baylor Scott & White Health Plan.

Submission of this form is not an automatic approval to BSWHP's network. We will contact you for more information or confirmation of your request.

* Required information

Group Name*

Group NPI

Provider Name*

Joined Group Date*

Specialty*

Provider Type*

Board Certified*

Tax ID*

NPI*

TPI Medicaid

Medicare No.

Phone*

FAX

Website

Contact Name*

Contact Position/Title*

Contact Email*

Contact Phone*

Ext.

Contact FAX

Comments/Notes

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