Letter of Interest - Community First Health Plans Step 1 of 5 20% Are you a Provider applying to join an existing Community First contracted group?* Yes No Instructions for Joining an Existing GroupIf you are a provider who is currently not contracted with Community First Health Plans and will be joining an existing group in our network, please complete the following form for each practitioner. Please allow up to 60 days for the provider to be credentialed, if needed, and added to the group.Instructions for Joining as a New GroupCommunity First Health Plans (Community First) continuously monitors and evaluates the availability and access to health care services provided in our network. Community First’s ongoing assessment of its provider network for availability and access standards ensures adequate services throughout the network. If you are interested in being considered for the Community First provider network, please complete the following form for each practitioner submitted for consideration. Please allow up to 60 days for your application to be reviewed. Practitioner First Name* Practitioner Last Name* Practitioner Title* Name of Group / Facility* Name of Group / Facility you are joining* Practitioner Phone Number*Practitioner Email Address* Does the provider speak any other languages?* Yes No Enter languages: Practitioner Website URL* Please input N/A if this does not apply. Do you have hospital privileges at any of the following: University Health System Methodist Healthcare Christus Santa Rosa Baptist Health System Medina Regional Hospital Texas Vista Medical Center Connally Memorial Medical Center Guadalupe Regional Medical Center Kindred Hospital Other Other: Service/Office Location* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Additional Office Location Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Additional Office Location Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country What days are your office open?* Sunday Monday Tuesday Wednesday Thursday Friday Saturday Sunday hours*(ex. 8a-5:30p) Monday hours*(ex. 8a-5:30p) Tuesday hours*(ex. 8a-5:30p) Wednesday hours*(ex. 8a-5:30p) Thursday hours*(ex. 8a-5:30p) Friday hours*(ex. 8a-5:30p) Saturday hours*(ex. 8a-5:30p) Counties Serviced:*Note: Community First Health Plans is a closed network and providers must service at least one or more of the counties listed below Bexar Atascosa Bandera Comal Guadalupe Kendall Medina Wilson Federal Tax ID #* NPI #* TPI #*(For Providers who accept Medicaid) TH Steps TPI #*(PCP only) CAQH #* Medicare #* API #*(LTSS only) Panel Restrictions*(If none, select None)noneAccepting Adults OnlyAccepting Ages 0 to 11Accepting Ages 0 to 12Accepting Ages 0 to 13Accepting Ages 0 to 14Accepting Ages 0 to 15Accepting Ages 0 to 16Accepting Ages 0 to 17Accepting Ages 0 to 18Accepting Ages 0 to 21, Women - all ages, Existing Adult MalesAccepting Ages 0 to 21Accepting Ages to 3Accepting Ages 0 to 30Accepting Ages 0 to 5 and Existing Pts Only & Siblings of Existing PtsAccepting Ages 0 to 13 (New Pts) & 14-16 (Existing Pts)Accepting Ages 0 to 14 (New Pts) & 15 and Older (Existing Pts)Accepting Ages 0-2 Years OldAccepting Ages 1 and OlderAccepting Ages 10 and OlderAccepting Ages 10 to 100, Females OnlyAccepting Ages 11 and OlderAccepting Ages 12 and OlderAccepting Ages 12 to 70Accepting Ages 12 to 85Accepting Ages 13 and OlderAccepting Ages 13 and Older, Females OnlyAccepting Ages 14 and OlderAccepting Ages 15 and OlderAccepting Ages 15 and Older, Females OnlyAccepting Ages 16 and OlderAccepting Ages 17 and OlderAccepting Ages 18 and OlderAccepting Ages 19 and OlderAccepting Ages 2 and OlderAccepting Ages 2 Months and OlderAccepting Ages 21 and OlderAccepting Ages 3 and OlderAccepting Ages 3 Months and OlderAccepting Ages 3 to 21Accepting Ages 4 and OlderAccepting Ages 4 to 17Accepting Ages 5 and OlderAccepting Ages 55 and OlderAccepting Ages 6 and OlderAccepting Ages 6 Months and OlderAccepting Ages 7 and OlderAccepting Ages 8 and OlderAccepting Ages 8 to 65Accepting Ages 9 Months and OlderAccepting Ages Existing Pts Only and New Pts Ages 0 to 2 Yrs OldAccepting Females OnlyAccepting Gynecological Patients OnlyAccepting New Patients Ages 0 to 17 and Any Existing Patient (Any Age)Accepting OBYGN Patients OnlyAccepting Pts Under Age 65Other Provider Type / SpecialtyPrimary Care ProviderSELECTFamily PracticeInternal MedicineGeriatricsPediatricsNurse PractitionersSpecialist Ancillary Behavioral HealthCheck all that apply LPC LCSW Psychologist Psychiatrist Substance Use Disorder Treatment Opioid Treatment ABA/LBA Targeted Case Management Residential Treatment/Facility Other Residential Treatment/Facility: Other: LTSS ProviderCheck all that apply Personal Attendant Services (PAS) Private Duty Nursing Financial Management Services Agency Home Delivered Meals Respite Care: In-Home Respite Care: Out of Home Day Activity & Health Services (DAHS) Habilitation Minor Home Modification Vehicle Modification Adaptive Aids Emergency Response System Transition Assistance Services Supported Employment Employment Assistance HCSSA EVV Other Other: Waiver Program Contract(check all that apply) MDCP Community First Choice (CFC Texas Home Health (TxHmL) Deaf Blind with Multiple Disabilities (DBMD) Community Living Assistance and Support Services YES Home and Community-based Services (HCS) Other: DME Provider Wheelchairs Sleep Equipment (CPAP and BiLevel) Enteral Nutrition products and equipment Incontinence and Urological Products Hospital Equipment and Bathroom Aides Disposable Diapers (Child and Adult) Ostomy Supplies Post Mastectomy Products Nebulizer Compressor and Supplies Bariatric Equipment Rehab Equipment Hospital Beds and Accessories Nutritional Supplements Diabetic Supplies Custom Burn Garments Suction Pump and Supplies Catherization Supplies Other Other: Home Health Provider Skilled Nursing Personal Care Assistant Respite Care Occupational Therapy Private Duty Nursing Nutrition Physical Therapy FMSA Hospice Other Other: Do you offer Telehealth?YesNoProducts of Interest* STAR Medicaid STAR Kids CHIP/CHIP Perinate Medicare Advantage (HMO) Commercial HMO Community First continues to grow its product lines of business. If you are interested in being considered for the following prospective lines of business, check below STAR +Plus Health Insurance Exchange (Marketplace) Contact Information of Person Submitting RequestName* Email* Phone*Organizations Federal StatusPlease identify your appropriate Federal Status, if applicable: Rural Health Clinic (RHC) Significant Traditional Provider (STP) Historically Underutilized Business (HUB) Federally Qualified Health Center (FQHC) Other InformationDocuments:Please include additional information or documentation (brochures, pamphlets) relevant to your request. Drop files here or Select files Max. file size: 50 MB. Comments(optional) Δ
