Behavioral Health Provider Network Participation Form

Please Note: This form is only for use by Behavioral Health Providers requesting to participate in the Seton Employee Plan (SmartHealth).

Behavioral Health Provider Type * Required
Behavioral Health Specialty * Required
Group/Provider Name
Provider Tax ID Number * Required
Group/Provider NPI Number * Required
Legal Name (as shown on your income tax return) * Required
Doing Business As (if different from above)
PLEASE NOTE: The Seton Employee Plan (SmartHealth) is only available in the following counties: Bastrop, Bell, Bosque, Burnet, Coryell, Falls, Hamilton, Hays, Hill, Limestone, McClennan, Travis, and Williamson.
Office Location or Service Area by County * Required
Contact Name * Required
Contact Email * Required
Contact Phone * Required
Provider Website Address - enter a valid website URL for example https://www.google.com
Upload Resume/CV * Required
Accepted file types: jpg, gif, png, pdf, doc, docx.
Comments
This field is for validation purposes and should be left unchanged.