To nominate a physician to participate in the contracting provider network, complete the form below. Prior to submitting your nomination, check the Provider Finder or ask the provider about his/her network status.

To recommend a physician to participate in the contracting provider network,

• Check that the physician is not already in the Provider Finder (or ask the provider about his/her network status).
• Complete the form below, an asterisk indicates a required field.

Other considerations:

• It may take up to 90 days for the provider to be accepted into a network.
• Providers must meet all established credentialing requirements.
• Providers must agree to all contract provisions, policies and procedures.
• Your recommendation does not guarantee that the provider will be accepted into the network.

Network: *
Physician First Name: *
Physician Last Name: *
Physician Middle Initial:
Hospital Affiliation:
Specialty Type: *	Family Practice Internal Medicine Pediatrics Other
Address: *
Address 2:
City: *
State: *	(example: OK)
Zip Code: *
County:
Physician Office Phone Number: *