Request to Join Our Network
TECQ Foundation / Van Lang IPA / TEACO Provider Network

After completing this form, someone from the Provider Network Operations team will reach out to you within 3-5 business days.  Feel free to email the team with your questions at any time:  
Provider-Support@tecqpartners.com


/// REF: N008-22006

Security Code: 8278  -- use this code to enter at the end of this form.
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1. Organization Name *
Same name on W9 as filed to the IRS for your medical company
2. Organization NPI *
If unknown, you can find your organization NPI here https://npiregistry.cms.hhs.gov/ 

IMPORTANT:  Can list more than one NPI if they have the same tax ID number
ALSO:  We are not currently contracting with organizations owned by mid-levels
3. Organization Service *
Identify the type of service your organization provides
REQUIRED:  IDENTIFY THE OWNER / AUTHORIZED OFFICIAL OF THE ORGANIZATION
This information will be verified against public records (NPI Registry, TSOS).
4. First Name *
Must be of OWNER OF TAX ID
5. Last Name *
Must be of OWNER OF TAX ID
6. Title *
Must be of OWNER OF TAX ID
7. Email *
Must be of OWNER OF TAX ID
8. Business Phone *
Must be of OWNER OF TAX ID
9. Mobile Phone
Must be of OWNER OF TAX ID
NOT REQUIRED:  ASSIGN A SEPARATE REVIEWER OF THE CONTRACT (this person will not have signature authority) 
10. First Name (reviewer)
11. Last Name (reviewer)
12. Title (reviewer)
13. Email (reviewer)
Email is mandatory if you want to create an account for this role.
14. Phone Number (reviewer)
REQUIRED:  SECURITY CODE *
Check the security code in the information section at the top, then input here
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