Join NTSP - North Texas Specialty Physicians

Physician Name*

First Last

Gender*

Male
Female

Primary Care Physician*

Yes
No

Physician's Degree*

M.D.
D.O.
D.P.M.

Physician's Primary Specialty:*

Physician's Primary Specialty: - Board Certified*

Yes
No

Physician's Sub-specialties:

Physician's Sub-specialties - Board Certified*

Yes
No

Invidivual NPI:*

Tax ID:*

Physician's Medicare #:*

CAQH #:*

Accepting new Medicare Advantage Patients?*

Yes
No

Physican's Practice Legal Name:*

Is Physician Part of a Group?*

Yes
No

Group Name:*

Are other physicians in your group members of NTSP?*

Yes
No

Please provide the names of the physicians who are members of NTSP:*

Practice Address*

Street Address Address Line 2 City State ZIP Code

Practice Phone #:*

Practice Fax #:*

Email address*

Do you have hospital admission privileges?*

Yes
No

If you do not have hospital admission privileges, please list the hospitalist group used:*

List all hospital privileges in North Texas:*

Are you currently contracted and credentialed with the following Medicare Advantage Plans (check all that apply)?*

Care N' Care HMO & PPO
Humana Gold HMO
UnitedHealthcare AARP MedicareComplete Secure Horizons

How did you hear about NTSP?*

Please tell us why you are interested in joining NTSP?*

Physician Office Contact Information

Contact person name and title:*

Email address*

Phone #*

Fax #*

Person completing this form:*

Date*

Membership Inquiry

Physician Office Contact Information

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