Nominations by Client

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Nominations by Client

This Nomination Form is for IHP Clients/Payors only – If you are a Provider wanting an Application, please arrow back to the last page and choose “Nomination by Provider”.

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.

If Payor/Client - Your Name:

Submitter's Name:

Submitter's Email Address:

Submitter's Phone Number:

Submitter's Comments:

Practice/Group Name:

Tax ID Number:

Number of Providers in Group/Practice:

Practice Address:

Practice City:

Practice State:

Practice Zip:

Practice Phone:

Practice Fax:

Practice Contact Person's Name:

Practice Contact Person's Email Address:

Practice Specialty:

Your Email:

Is Practice/Group part of PHO or IPA?:

Yes
No
Unknown

Comments:

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