Letter of Interest
Please complete the Letter of Interest Questionnaire for each provider and return to Network
Development by fax 682-885-8403 or email CCHPNetworkDevelopment@cookchildrens.org.
A current W-9 form must be included with this form for processing.
Provider Information
Organization Name: ________________________________________________________
Type of Services Provided: ___________________________________________________
Last Name: ___________________________First Name: __________________________
Date of Birth: _______________ NPI or API: ________________ TPI: _________________
CAQH Number: ___________________________________________________________
Primary Speciality: ____________________ Secondary Specialty: ___________________
Board Certified: Yes No If No, Completion Date of Residency: ___________________
Hospital Privileges: _________________________________________________________
Physician(s) for call coverage: ________________________________________________
Practice Information
Facility Group Individual
Practice Name: ____________________________________________________________
Practice Address: _______________________________________City: _______________
State: _______ Zip: _________ Phone: __________________ Fax: __________________
Tax ID: ___________________ NPI or API: ________________ TPI: ________________
Contact Name: __________________________ Contact Phone: _____________________
Contact Email: ____________________________________________________________
Mailing Information
Mailing Name: _____________________________________________________________
Mailing Address: _______________________________________ City: ________________
State: ___________________ Zip: ____________________________________________
Credentialing Information
Contact Name: __________________________ Title: _____________________________
Phone: _________________ Fax: ____________________________________________
Contact Email: ____________________________________________________________
Office Information
Panel status: Open Closed Existing only
Age restrictions: Yes No If yes, please explain _______________________________
Do you treat: Children Adults Pregnant Women
Patients gender: Male Female Both
Directory print: Yes No
Languages spoken: _______________________________Interpreter Provider/Staff
Office hours: __________ Extended hours: __________ Handicap accessible: Yes No
Completed Cultural Competency Training Yes No
Fax or Email Attestation to Network Development
Office Information
If you are a PCP do you provide EPSDT (Texas Health Steps) Services? Yes No
Are you contracted with and Electronic Visit Verification (EVV) vendor?
Yes No If yes, please list vendor name: _____________________________________
Do you provide: Telehealth Tele-monitoring Telemedicine
Long Term Services and Supports (LTSS)
Adaptive Aides / Medical Equipment (DME)
Adult Day Care/Day Activity and Health Services
Adult Foster Care
Assisted Living/Residential Care/Group Home
Emergency Response System
Employment Assistance
Flexible Family Support Services
Financial Management Service (FI) (CDS)
Habilitation (PAS/HAB) (CFC)
Home & Community Support Services (HCSSA)
Home Delivered Meals
Medically Dependent Children Program (MDCP)
Minor Home Mods
Nursing Facility
Occupational Therapy
Personal Assistance Services (CFC)
Personal Assistance Services/Personal Care Services/Attendant Care/Primary Home Care (Agency
Personal Assistance Services/Personal Care Services/Attendant Care/Primary Home (Service
Responsibility Option)
Prescribed Pediatric Extended Care Centers (PPECC)
Physical Therapy
Private Duty Nursing (PDN)
Respite Care (In Home)-Personal Assistance Service
Respite Care (In Home)-Nursing
Respite Care (Facility)
Skilled Nursing
Speech Therapy
Supported Employment
Transition Assistance Services
Vehicle Mods Specialized
Other: __________________________________________________________________
Counties Served: ___________________________________________________________
Completed by: ______________________________________Date: __________________
Email CCPHNetworkdevelopment@cookchildrens.org with any questions or concerns.
When the credentialing process is initiated for practitioners and organizations, the applicant is
entitled to:
1. Review the information submitted to support their credentialing application
2. Correct erroneous information
3. Receive the status of their credentialing or recredentialing application, upon request.