PONI - Physician Optimal Network Incorporated

Getting started is simple!

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

Submit your COMPLETE package by EMAIL (Scanned Copies), Fax, U.S. Mail or Overnight Delivery Services to:

Cypress Healthcare Consultants

500 N. Central Expressway, Suite 500

Plano, TX 75074

[email protected]

Call us at: (972) 424-1360

INCOMPLETE APPLICATION PACKETS CANNOT BE PROCESSED. THERE WILL BE NO EXCEPTIONS.

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.