Texas

LICENSING CERTIFICATION & COMPLIANCE

QUICK SERVICE FORM

The Information Below will be used to Prepare The Agreement

Info Need on Person Responsible

First Name

Last Name

Email

Company Legal Name

Address

City, State & Zip

Direct Phone of Person Signing the Contract

Select the Services Needed:

HHSC Contract (PHC,FC,CAS )$975

Texas Caregiver Contract(HHSC pays $40/per hr) $975

Texas Hospital Sitter Contract(HHSC Pays $25 per hr) $975

State License Renewals $975.00

State License (Change of Ownerships) $750

Initial Medicaid Provider Number $475.00

Initial Medicare Provider Number $600.00

Medicare Provider/Medicaid Revalidation $475

Medicaid & HHSC Contract (PHC) $825

Texas Caregiver Contract & Hospital Sitter Contract $1525

State Renewal, Medicaid & HHSC Contract $1225

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.

Texas

LICENSING CERTIFICATION & COMPLIANCE

2440 Texas Parkway Ste 385

Missouri City TX 77489

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Texas

QUICK SERVICE FORM

The Information Below will be used to Prepare The Agreement

Texas

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