Member Log In

Application & Checklist

Applicant should complete and return the following:

Texas Common Credentialing Application Part I:

Personal Information
Facilities Affiliations
Office Information
Professional Work History
Professional Liability Insurance
Malpractice Claims History
Case Specific Liability Claims InInformation
Certifications and Registrations
Current Professional Practice
Academic Appointments
Signature Section

Required Attachments:

Current State License
Texas Controlled Substances Registration Certification
Current Federal DEA Registration
Current Professional Liability Insurance Face Sheet

Texas Common Credentialing Application Part II:

Peer References
Continuing Medical Education Information
Attestation Questions
Doctor's Verification and Release Form
Other Requested Information

Documents Requested:

Curriculum Vitae and CME hours
Board Certification Certificate
Medical School Certificate
Internship & Residency Certificates (All)
Fellowship Certificates (If Applicable)
All Mid-Level Practitioners Liscenses
ECFMG (If Applicable)
Current Texas Medical License
Current DEA
Current DPS
Current Certificate of Insurance
Current General Liability Certificate of Insurance
Narrative on Malpractice Cases (If Applicable)
W-9 Tax I.D. Number Certification

Please Note: All sheets of application must be initialed and dated!

Also enclose: $350 non-refundable application fee

Please make the checks payable to Physicians Contracting Organization of Texas, and mail the information to:

Physicians Contracting Organization of Texas
305 South Broadway Ste. 700
Tyler, Texas 75702
(903) 526-3268

Please note: incomplete applications will delay the credentialing process!

Download Options

Our membership application and other forms, described below, are available the Portable Document Format (PDF).  In order to view and print them, you will need Adobe® Acrobat® Reader version 4.0 or later.  You may download this program for free by clicking here, which will give you the download information in a new browser window.