New Provider
Please complete the entire application, including answering all questions and attach copies of the following documents:
Current licenses (including DEA)
Current malpractice insurance coverage
Certification documentation
W-9
Curriculum Vitae
Complete chart notes from the last three work-related injury patients you have treated, including first visit through last. Please mask names for confidentiality.
Applications received without the appropriate documentation cannot be reviewed.
Please return this application and the required documents to Majoris via U. S. Mail to:
Majoris Health Systems, Inc.
Attn: Provider Relations
106 E. Sixth Street, Suite 900
Austin, TX 78701
Or you may fax this information to us toll free to 503-601-8438
Click here to download a Texas application
If you are interested in becoming a provider for one of our member networks (Majoris Health Systems in Texas or Montana Health Systems in Montana), please be sure to download the application on the member websites listed on the left hand side of this page.