Nominate a Provider to Our Network | HealthLink

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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

* Name

* Address

* City

* State

* Zip Code

* Phone

Fax

* Email

* I am a

Not Listed (Please Specify)

Provider Information

* Physician Name

Associated Physician Group

Specialty

Comments

Primary Office Address

* Address

* City

* State

* Zip Code

* Phone

Fax

Hospital Privileges

Primary

Secondary