Get Dhp Request For Contract Form - Driscoll Health Plan

Completing the DHP Request For Contract Form for Driscoll Health Plan is a straightforward process that can be done online. This guide will provide you with clear and detailed instructions to help you fill out the necessary fields accurately and efficiently.

Follow the steps to complete the form online:

1. Press the ‘Get Form’ button to access the DHP Request For Contract Form and open it for editing.
2. Begin by filling in the date of your request in the designated field at the top of the form.
3. Enter your name as the individual making the request in the 'Requested by' section along with your title.
4. Provide your contact information, including your phone number and email address, to ensure you can be reached regarding the contract.
5. Fill out the main provider information. This includes the provider name, group name, tax ID, group NPI, group TPI, specialty, taxonomy, individual TPI, individual NPI, and CAQH number.
6. Input the physical address or primary place of service (POS) along with the billing address, ensuring that the billing address is a physical address and differs from the billing company.
7. Provide the mailing address, ensuring that it includes the city, state, and zip code.
8. If applicable, fill in the pay-to address with the necessary contact information.
9. Review the 'For Office Use Only' section to understand the requirements for credentialing documentation. Ensure that you have all necessary documents ready, such as the W-9, Texas license, and liability insurance.
10. After ensuring all fields are correctly filled out, save your changes. You can then download, print, or share the completed form as needed.

Complete your DHP Request For Contract Form online today to establish your contract with the Driscoll Health Plan.