Tel. 1-800-962-4961

Texas

REGULATORY LICENSING

& COMPLIANCE LLC

Regulatory Licensing & Compliance

"Need Licensing Come to a Licensing Expert"

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CONTRACT REQUEST

The Information Below will be used to Prepare The Agreement

Person Signing Contract

First Name

Last Name

Company Legal Name

Address

City, State & Zip

Direct Phone of Person Signing the Contract

What Services Do you Need:

NEW Homecare Agency LICENSE(PAS): $5925 **Discounted**

NEW Homehealth Agency LICENSE(PAS): $6925 **Discounted**

NEW Hospice Agency LICENSE(PAS): $7425 **Discounted**

Medicare Provider Re-Enrollment $475

Medicaid Provider Re-Enrollment $475

HHSC Community Service Contract (PHC,FC,CAS)$600

Texas Caregiver Contract(State Pays $40/per hour)$1,500.00(** Discounted)

State License Renewals, Upgrades $500.00

State License (Change of Ownerships) $750.00

Initial Medicaid Provider Number $600.00

Initial Medicare Provider Number $600.00

Medicaid Provider Number & HHSC Contract (PHC,FC,CAS)(Package)$995.00

Medicaid Provider Number & State Renewal (Package) $775.00

Texas Hospital Sitter & Texas Caregiver Contract (Package)$2500.00

Coupon Code (If Any)

This form is needed to prepare an agreement to send to you. Please fill this form out completely. If you have any questions please call us at:1-800-962-4961 Ext. 1 or you can email us at: Contracts@txrlc.com.

PLEASE NOTE: WE WILL SEND THE AGREEMENT TO THE EMAIL WITH THE INFO YOU INPUT ABOVE.

Regulatory Licensing & Compliance

3727 Greenbriar Drive Suite 115
Stafford Texas 77477

Tel. 1-800-962-4961

Fax. 281-817-5904

Email. info@txrlc.com

Services Provided in the Following States

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