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First Name*

Last Name*

Practice/Group Name*

Position or Role

Email Address*

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Address*

Address 2
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City*

State*

Zip*
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National Provider Identifier (NPI)*
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Service Delivery Area (SDA)*
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Bexar

Dallas

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Harris

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Lubbock

MRSA Central

MRSA Northeast

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Nueces

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Products*
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Wellcare By Allwell (HMO)

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Ambetter from Superior HealthPlan - Health Insurance Marketplace

CHIP/CHIP Perinate

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STAR Health

STAR Kids

STAR+PLUS

STAR+PLUS Medicare-Medicaid Plan (MMP)

Specialty Type*
(please select all that apply)

Adult Day Care or Assisted Living	Neurology
Allergy or Immunology	Nursing Facility
Ambulatory	OB/GYN
Anesthesia	Orthopedics
Audiology	Optometry
Behavioral Health or Counselor	Oncology
Cardiology	Therapy (Physical/Occupational/Speech)
Critical Care or Emergency Medicine	Pathology
Dental	Pharmacy
Dermatology	Pediatrics
Durable Medical Equipment (DME)	Podiatry
Ear, Nose and Throat (ENT)	Primary Care Provider (PCP)
Endocrinology	Pulmonology
Federally Qualified Health Center (FQHC)	Radiology
Gastroenterology	Rheumatology
Home Health	Rural Health Clinic
Hospital	Skilled Nursing Facility
Interventional Pain Management	Urgent Care
Long-Term Services and Supports (LTSS)	Urology
Nephrology	Other