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Nominate a Doctor, Hospital or Other Health Care Facility to Join the HealthLink Network

If there is a health care provider that you would like to nominate for consideration into the HealthLink network, please fill in the fields below and click Submit. Please note this nomination does not guarantee the provider will become a part of the HealthLink network. The contracting and credentialing process can take 90-120 days.

Notice! You are currently viewing the abbreviated provider nomination form. If you are a health care provider, please use the full form.

Requestor Information
Provider Information
Primary Office Address
Hospital Privileges