Provider Nomination Form

Do you have a favorite provider who is not a participant in our network?

As a member, you can nominate an individual provider for consideration in the Healthcare Highways network. Simply complete the form below and hit “submit.”


Some details that you should know:

  1. Your nomination does not guarantee that the provider will be accepted to participate in a Healthcare Highways network.
  2. Providers must satisfy our business requirements, including, but not limited to, Healthcare Highways’ credentialing and contracting requirements.
  3. The nomination process takes 90-120 days.

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


If you are a provider and wish to join our network, go here.

*indicates required field

Name of member nominating a provider

Provider information

May we use you as a reference?

 Yes

 No