Contracted Provider Forms

• PlanLink Access Request Form
• 2024 Authorization Request Form
• Claim Submission Information
• Transition of Care/Continuity of Care Form

List of Prior Authorization Codes

• Kelsey Care Advantage Prior Authorization list effective 4/8/2024

Become An Affiliate Provider

If you are interested in becoming a contracted provider with Kelsey-Seybold Clinic please submit a Letter of Interest (LOI).

Letter Of Interest (LOI) Requirements

Please include the following information in your LOI:

• a company overview
• services provided
• your location(s)
• geographical coverage areas
• specialty services
• medical staff roster, if applicable.

Letters can be submitted via:
Email: affiliateproviders@kelsey-seybold.com
Fax: (713) 442-2775

Kelsey-Seybold Clinic
Attn: Network Development
11511 Shadow Creek Parkway
Pearland, Texas 77584

Affiliate Provider Application Response Timeline

Provider selection is based on numerous factors. You will receive notification regarding the Plan's decision to enter into an agreement generally within six (6) weeks of submission of the LOI.

Authorization Request Form Archive

• 2023 Authorization Request Form