Nominations by Provider

Nominations by Provider

This Nomination Form is to request an Application Packet for a specific Provider, Facility or Group of Providers to join the IHP PPO Network.

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.

Practice/Group Name:

Tax ID Number:

Number of Providers in Group/Practice:

Provider Name(s):

Practice Address:

Practice City:

Practice State:

Practice Zip:

Practice Phone:

Practice Fax:

Your Name:

Your Email:

Practice Specialty:

Is Practice/Group part of PHO or IPA?:

Yes
No

Please send my Application Packet via:

Fax to the number above
Email to the address above

Comments:

Send Reset