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Nomination Form
Nomination Form to Join the Prime Healthcare Network
Note: Attempt will be made to contract nominated provider to Tier 1, however nomination is not a guarantee that provider can be added to Tier 1 due to various factors and consideration.
Member’s Information:
Name:
*
Prime Facility:
*
Phone
:
*
Email
Provider's Information:
Provider’s Name:
*
Specialty:
*
Group/Facility Name:
Address:
City
:
State:
*
Zip:
*
Phone:
*
Fax:
Email:
*
Additional Comments - i.e., reason for request:
Submit