NOMINATIONS

Nominations

To nominate a provider please fill in the information below.

Please contact Integrated Health Plan, Inc. at 1.888.640.8707 or e-mail: info@ihplan.com should you have any questions regarding this form.

Practitioner Name:

Practice/Group Name:

Address:

City:

Zip:

Phone:

Fax:

Specialty:

Nominated By:

Your Email:

Comments:

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Leadership Team