Application and Checklist
PCOT application forms and checklist
Here’s everything you need in order to apply for membership to the PCOT
Membership application forms
Download the following forms and fill out the details in order to start your application process to the PCOT.
Application Downloads
Credentialing checklist
Provide all of the items listed below to be credentialed to join the PCOT. Please note that incomplete applications will delay the credentialing process.
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 Licenses
- ECFMG (If Applicable)
- Current Texas Medical License
- Current DEA
- Current Certificate of Malpractice Insurance
- Narrative on Malpractice Cases (If Applicable)
- W-9 Tax I.D. Number Certification
Mailing address
Send all application forms and credentialing documents to:
Physicians Contracting Organization of Texas
305 South Broadway Ste. 700
Tyler, Texas 75702
(903) 526-3268
Please enclose the $350 non-refundable application fee.
All checks should be made payable to Physicians Contracting Organization of Texas.
Credentialing process
- 1. Logging data
- If application is complete: PCOT logs application and enters demographics into electronic system.
- If application is incomplete: PCOT returns application to physician and executes follow-up ticker mechanism in database.
- 2. Credentialing
- Enter data with accompanying credentials (licensure).
- Create index file.
- Run on-line verifications.
- Audit verifications.
- Prepare for Credentialing Committee.
- 3. Approval
- PCOT Credentialing Committee approve or deny credentialing and membership, and the Board of Directors oversees Credentialing Committee decision.
- 4.Payor and Plans
- PCOT Physician Services Representative delivers opt in/opt out packages to physicians.
- Physician completes and returns information.
- PCOT enters data and notifies Health Plans.
PCOT is not responsible for any of the following delays:
- Failure by the physician to provide completed application (including all supporting documents) in a timely manner.
- Failure by the physician to obtain adequate hospital privileges as required by PCOT.
- Postponement of board meetings, and subsequent membership decision.
- Failure by physician to return opt in/opt out packages on time.
- Failure by Health Plans to assign and enter effective dates into their system and to notify PCOT in a timely manner.
The response times by the providers, hospital, Board, and Health Plans are all variables that make up the timeline, none of which PCOT can directly control.
On average, the entire application process from time of application to date of acceptance for PCOT is less than 60 days.