Fillable PROVIDER NOMINATION FORM

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PROVIDER NOMINATION FORM

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PRONOM1HSN1021
PROVIDER NOMINATION FORM
If your medical or dental provider is not currently included in DMBA’s contracted provider network, follow these steps to request that she/he
be considered for participation:
1. Approach your provider and express your desire for him/her to become part of DMBA’s network.
2. If the provider is interested in contracting with DMBA, complete this form.
3. If DMBA extends an invitation to the provider to submit an application, the contracting process may take up to 90 days. Contact your
provider directly if you have any questions about the status of the application.
All requested information must be provided for the provider to be considered. This nomination will be carefully evaluated, but it does not
guarantee the provider will be added to the network.
REFERRAL INFORMATION (COMPLETED BY REFERRING MEMBER)
REFERRING MEMBER
DMBA ID NUMBER
DETAILED REASON FOR NOMINATING THIS PROVIDER
PROVIDER INFORMATION (COMPLETED BY NOMINATED MEDICAL/DENTAL PROVIDER)
FIRST NAME
MIDDLE INITIAL
LAST NAME
DEGREE
SPECIALTY
YEARS IN PRACTICE
PRACTICE NAME
STREE ADDRESS
PHONE NUMBER
CITY
STATE
ZIP CODE
COUNTY
Mail completed form to:
DMBA
Attn: Healthcare Systems
P.O. Box 45530
Salt Lake City, UT 84145
Email completed form to: providerrelations@dmba.com
For questions about this form, call DMBA’s Provider Relations
at 801-578-5600 and choose options 1, 3, and then 5. Or call
us toll free at 800-777-3622.
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PROVIDER NOMINATION FORM

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Completed 23 November 2021

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