Letter of Interest
Questionnaire
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
RevNov2020
