Recommend a Provider for the HealthSelect Network

If your doctor or other provider is not currently in the HealthSelect network, you can recommend that they be added by filling out this form.

Please keep in mind:

• Your recommendation does not guarantee that the provider will be accepted into the network.
• It may take up to 90 days for the provider to be accepted into the network.
• Providers must meet all established credentialing requirements.
• Providers must agree to all contract provisions, policies and procedures.

An asterisk (^*) indicates a required field.

Network:^* - select a network - HealthSelect of Texas In-Area Consumer Directed HealthSelect HealthSelect Secondary HealthSelect of Texas Out-of-State

Physician name or facility name:^*

Hospital affiliation (if any):

Specialty type (select):^*

Family practice
Internal medicine
Mental health
Pediatrics
Other

Physician address:^*

Physician address 2:

Physician city:^*

Physician state:^* - select a state - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Physician ZIP code:^*

Physician county:

Physician office phone number:^*

NPI ID:

TAX ID: