PPO Scheduled Service Notification

*Required Field

*Member Group #:
*Member ID #:
*Patient Name:
*Patient DOB:
*Date of Service:
*Provider Name:
*Rendering or Attending Provider NPI:
*Billing Provider NPI:
 

 

Submission of this form is notification as required by the Texas Department of Insurance Subchapter X. Preferred and Exclusive Provider Plans Division 1. General Requirements 28 T AC §§3.3701 - 3.3710.