Please complete this form if you would like to amend your current BSWHP contract, which includes adding BSWHP products to existing agreement, TIN or legal name change, contract rate negotiations, adding services to your existing contract, etc. Please complete all fields. Enter N/A if a field is not applicable to you.
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Not all required elements have text entered or a value selected. Please enter values for all of the fields in the color of this box below. Once done, click the "Submit" button again.
Please provide a detailed explanation in the comment section regarding the modifications you would like to make to your current BSWHP contract:
Thank you again for your request to add a provider to your Scott and White Health Plan contracted group. Please allow 30-45 days before checking on status.
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