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Member Center
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Nominate a Provider
Nominate a Provider Form
To nominate a physician to participate in the HealthSmart provider network, please complete the form below.
Your Information
Your Last Name:
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Your First Name:
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Your E-mail:
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Your Phone:
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Example: (555) 555-5555 or 555-555-5555
Your Employer Name:
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Comments Or Special Instructions:
Provider and/or Facility Information
Provider and/or Facility Name:
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Provider Specialty Type:
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Provider Phone:
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Example: (555) 555-5555 or 555-555-5555
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