Contracted Provider Forms
List of Prior Authorization Codes
Become An Affiliate Provider
If you are interested in becoming a contracted provider with Kelsey-Seybold Clinic please submit a Letter of Interest (LOI).
Letter Of Interest (LOI) Requirements
Please include the following information in your LOI:
- a company overview
- services provided
- your location(s)
- geographical coverage areas
- specialty services
- medical staff roster, if applicable.
Letters can be submitted via:
Fax: (713) 442-2775
Attn: Network Development
11511 Shadow Creek Parkway
Pearland, Texas 77584
Affiliate Provider Application Response Timeline
Provider selection is based on numerous factors. You will receive notification regarding the Plan's decision to enter into an agreement generally within six (6) weeks of submission of the LOI.