Provider Nomination Form

Provider Nomination Form

Please use this form to nominate an individual medical provider only.

Please complete this online form if you wish to recommend a provider for possible contracting for the Healthcare Highways network. Please note this nomination does not guarantee the nominated practitioner will become a participating provider of Healthcare Highways. Providers must satisfy our business needs and requirements, including, but not limited to Healthcare Highways’ credentialing and contracting requirements.

Please note that the nomination process can take 90-120 days.

If you have any questions regarding a provider nomination, please call Service Operations at: (866) 945-2292.

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