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:  The form can also be saved and completed then sent as an e-mail attachment. 

Note: If you are using Chrome, the “Submit by Email” button at the bottom of the form form may not work.  If it doesn't give you an option to open an e-mail automatically, it will need to be saved and manually attached to an e-mail then sent to the Texas Primary Care Office at

Option 2:  Complete and submit by fax:

Complete the  Healthcare Provider Assessment fillable PDF form, print, and submit the form to the TPCO by fax: (512) 776-4232.  The form can also be printed and completed by hand prior to faxing.

Definitions for commonly used terms and acronyms are on the TPCO Definitions page

Last updated April 21, 2021