Network Participation Form - Dell Children's Health Plan

Medical Provider Type *

Provider Type *

Your Primary Care Focus *

Choose Your Specialty *

Your Primary Care/Specialist *

Type of Ancillary Service Provided *

Group/Provider Name

Provider Tax ID Number *

Group/Provider NPI Number *

Legal Name (as shown on your income tax return) *

Doing Business As (if different from above):

Are you currently a Significant Traditional Provider for Texas Medicaid? *

Yes
No

Please Note: Seton Employee Plan (SmartHealth) is only available in the following counties: Bastrop, Bell, Bosque, Burnet, Coryell, Hays, Falls, Limestone, McLennan, Hamilton, Hill, Travis and Williamson.

Dell Children’s CHIP and STAR are only available in the following counties: Bastrop, Burnet, Caldwell, Fayette, Hays, Lee, Travis and Williamson.

Plans of Interest (Please select all that apply) *

CHIP
STAR
Seton Employee Plan (SmartHealth)
Ascension Personalized Care

Office Location or Service Area by County *

Contact Name *

Contact Email *

Contact Phone *

Provider Website Address

Phone

This field is for validation purposes and should be left unchanged.