Dental Provider Nomination Form

GEHA members, providers or office personnel may use this form to nominate a dentist to the GEHA Connection Dental^® Network.

GEHA members, providers or office personnel may use this form to nominate a dentist to the GEHA Connection Dental® Network. If the dentist of your choice is not listed in the online directory, you may complete this form to nominate the dentist to participate in the Connection Dental network. An application packet and information about Connection Dental will be sent to eligible providers. If your dentist chooses to join the network, the normal time frame to complete the nomination process is about 60 days.

Provider Information

Provider Tax ID # *

(if known)

Provider First Name *

Provider Middle Initial

Provider Last Name *

Facility Name *

Physical Address *

City *

State AA AE Alabama Alaska AP Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Other Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming *

ZIP Code *

Please enter the Provider's five-digit ZIP Code.

Daytime Phone Number *

Fax

Specialty

Member Information

Member ID# *

Member First Name

Member Middle Initial

Member Last Name *

Member Address *

Member City *

Member State AA AE Alabama Alaska AP Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Other Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming *

Member ZIP Code *

Please enter the Member's five-digit ZIP Code.

Member Daytime Phone Number

Member Fax

Email Address *

By providing your email address, you agree to receive email news and information from GEHA. You have the ability to opt out from within any email communication you receive from GEHA.

Comments