Texas HCN Provider Application

Please note: This application is specific to the Texas HCN. Liberty Mutual’s Managed Care Plans are available to customers/policyholders of Liberty Mutual Insurance and Helmsman Management Services. Not all customers/policyholders of Liberty Mutual Insurance and Helmsman Management Services choose to access Liberty’s Managed Care Plans.Providers interested in participation in Liberty's Managed Care Plans should first confirm that the employers for which they seek to provide medical services are customers of Liberty Mutual Insurance or Helmsman Management Services and that those customers are accessing Liberty's Managed Care Plans.

For questions regarding this information, please refer to the Contact Us section of this website.
*Indicates Required Entry

Provider Information

	Provider Group Name:
	Provider Name:
*	First Name:
	Middle Initial:
*	Last Name:
*	Tax Identification Number (TIN):	-
*	Specialty:

*	Are you accepting new WC patients?
*	Are you certified to conduct Maximum Medical Improvement (MMI) & Impairment Ratings (IR)?
*	Are you contracted for workers' compensation with Coventry?

To be considered for the LM TX HCN you must have an HCN contract for Workers' Compensation (WC) with Coventry. For information on completing all contracting and credentialing requirements, please contact Coventry Provider Relations at 800-973-6824. Once you become a part of the Coventry Network, you may apply for consideration by the Liberty HCN.

Provider Contact Information

*	Provider Contact Name:
*	Provider Contact Phone Number:	- - Ext:
*	Provider Contact Email:
*	Primary Physical Address-Street (Line 1):
	Primary Physical Address-Street (Line 2):
*	Primary Physical Address-City:
*	Primary Physical Address-ZIP:

Provider Hospital Affiliations:

Hospital Name(s) and City:

Provider Ambulatory Surgery Center Affiliations

ASC Name(s) and City:

Comments:

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