Texas

REGULATORY LICENSING

& COMPLIANCE LLC

Regulatory Licensing & Compliance

"Need Licensing Come to a Licensing Expert"

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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 )$475

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

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

State License Renewals $475.00

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 Regulatory Licensing & Compliance LLC

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

Alabama• Alaska •Arizona •Arkansas •California •Colorado •Connecticut •Delaware •Florida •Georgia •Hawaii •Idaho •Illinois •Indiana •Iowa •Kansas •Kentucky •Louisiana •Maine •Maryland •Massachusetts •Michigan •Minnesota •Mississippi •Missouri •Montana •Nebraska •Nevada •New Hampshire •New Jersey •New Mexico •New York •North Carolina •North Dakota •Ohio •Oklahoma •Oregon •Pennsylvania •Rhode Island •South Carolina •South Dakota •Tennessee •Texas •Utah •Vermont •Virginia •Washington •West Virginia •Wisconsin •Wyoming

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