TPCO Healthcare Provider Assessment

Who needs to fill out a Healthcare Provider Assessment?

  • Primary Care Physicians (MD or DO)
    • Family/General Practice
    • Internal Medicine
    • OB/GYN
    • Pediatrics

  • Psychiatrists (MD or DO)

  • Dentists (DDS or DMD)
    • General Dentistry
    • Pediatric Dentistry

Note:  Please complete a separate assessment for each healthcare provider in your office.  If a provider practices at multiple locations, please fill out a separate assessment for each additional location.

For questions or further information, please visit our Frequently Asked Question (FAQ) page.


To submit a Healthcare Provider Assessment:  

Option 1:  Complete and submit a fillable form via email:

Complete the Healthcare Provider Assessment fillable PDF form and click the “Submit by Email” button at the bottom of the form to submit the form directly to the Texas Primary Care email box:

Option 2:  Complete and submit by fax:

Complete the Healthcare Provider Assessment and submit the form to the TPCO by fax: (512) 776-4232.



Last updated June 30, 2020