Download the Participation Application and complete, sign, date and return the following:
- Texas Standardized Credentialing Application (TSCA)
- Participating Practice Agreement
- Business Associate Agreement
- IRS Form W-9 (make sure the information you provide on this form is identical to the information the IRS provided when they issued your federal employer identification number)
- Texas Workers’ Compensation Required Information Form
- Supplemental Credentialing Information Form
- New Provider Invoice with a check made payable to Physician Optimal Network, Inc. for credentialing and initial annual membership assessment
All done?
Submit your COMPLETE package by:
-
U.S. Mail or Overnight Delivery Services:
PONI Credentialing Verification
Cypress Healthcare Consultants
500 N Central Expressway, Suite 500
Plano, TX 75074 - EMAIL (Scanned Copies): join@poninetwork.com
- Fax: (972) 424-1360
INCOMPLETE APPLICATION PACKETS CANNOT BE PROCESSED. THERE WILL BE NO EXCEPTIONS.
Your Application Packet must contain:
- A completed Application – all aspects of the Application must be complete or marked “not applicable.” Blanks without explanation will not be accepted and will result in a rejected application.
- 100% of the Supporting Documentation required to accompany your Application.
- 100% of your Supporting Documentation must be current. If ANY documentation is expired, your Application will be rejected as incomplete.
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