Fillable Dentist Nomination Form (GEHA)

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Dentist Nomination Form (GEHA)

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Country of origin: US
File type: PDF

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CD-FRM-1018-001
Dentist Nomination Form
You can use this form to nominate a dentist to participate in the Connection Dental
Network. An application packet will be sent to eligible providers. The normal time frame
for credentialing of dentists takes about 60 days after application has been received.
Dentist information
Name:
Address:
Phone: Fax:
Member information
Name:
Address:
Phone: Fax:
Member ID number:
Employer group name: Group number:
Please mail this completed form to the following address:
GEHA Dental Administration
P.O. Box 21542
Eagan, MN 55121-9930
Or fax your completed form to GEHA Dental Administration at 816.257.3358
Thank you for your interest in the Connection Dental Network.
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Dentist Nomination Form (GEHA)

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Completed 21 May 2021

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