PBC Newsbrief
|Dental Provider Nomination Form |
Please verify participation status of your dental provider by checking with your dental provider, using Find a Doctor tool at , or contacting customer service prior to submitting a nomination form. In order to initiate contracting efforts on your behalf, the following information is required. Please print clearly.
|Date: | | |
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|Employer name: | |
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|Employee name: |Last | |First | |MI | |
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|Employee email address: | |
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|Submitted by (if different than employee): | |
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|Daytime phone number: |( ) -- |
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|Mailing address: | |
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|Provider’s full name: | |
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|Provider specialty/type: | |
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|Provider website address (if available): | |
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|Provider clinic or organization name: | |
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|Provider address: | |City: | |
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|State: | |ZIP: | |Provider phone: |( ) -- |
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|Additional information: | |
Upon completion of this form, please submit via email to PRpartners@.
Note: It normally takes approximately 90 days to determine provider participation. A nomination isn’t a guarantee that the provider will become contracted. Contracting is subject to applicable credentialing standards. Please follow up with your dental provider regarding the status of his or her participation.
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