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Provider Network Development
Provider-Support@tecqpartners.com

TECQ Foundation
8278 Bellaire Blvd, Ste B
Houston, TX 77036

/// REF: N008-22006

PPA = Participating Provider Agreement

Security Code: 8278  -- use this code to enter at the end of this form.
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1. Organization Name *
Same as name on W9 as filed to the IRS for your medical company
2. Group NPI *
Group NPI can be looked up here https://npiregistry.cms.hhs.gov/ 
3. Organization's Primary Contact Person *
Input details: contact first name and last name, contact title [e.g. Gordon Bunch, Provider Network Development, Executive Manager]
4. Organization's Primary Phone Number *
Input 10 digits [ e.g. (832) 272-7838 ]
5. Organization's Primary Fax Number
Input 10 digits [ e.g. (832) 272-7838 ]
6. Organization's Primary Address *
Input details: street name, city, state, ZIP Code... [ e.g. 8278 Bellaire Blvd, Ste B, Houston, Texas 77036 ]
7. Organization Service *
Indicate 1 organization service
INDIVIDUAL THAT IS THE OWNER OF THE ORGANIZATION / TAX ID (i.e. Provider Group)
8. First Name *
Must be of OWNER OF TAX ID
9. Last Name *
Must be of OWNER OF TAX ID
10. Title *
Must be of OWNER OF TAX ID
11. Email *
Must be of OWNER OF TAX ID
12. Business Phone *
Must be of OWNER OF TAX ID
13. Mobile Phone
Must be of OWNER OF TAX ID
INDIVIDUAL [editor] THAT CAN EDIT DOCUMENTS (optional)
This person will have permission to prepare and edit the documents, but not to sign them.
14. First Name (editor role)
15. Last Name (editor role)
16. Title (editor role)
17. Email (editor role)
Email is mandatory if you want to create an account for this role.
18. Phone Number (editor role)
Security Code *
Check the security code in the information section at the top, then input here
Submit
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