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Application & Checklist

Applicant should complete and return the following:


Texas Common Credentialing Application Part I:

Personal Information
Facilities Affiliations
Office Information
Professional Work History
Education
Professional Liability Insurance
Training
Malpractice Claims History
Licensure
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.