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: |      |

| | | |

|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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