Attention PPO ChoiceMembers:

Members covered under this option can nominate a non-participating provider to provide services at the in-network level of benefits. To assist you in understanding the nomination process, we have provided you with initial forms and instructions on how to nominate a provider. Please be aware that all forms and attachments must be complete before we can begin processing your nomination.

Complete the following steps:

• You should complete the top portion of the provider nomination form
• Take the provider nomination form, along with the attached W-9 form
• Have the nominated provider complete the bottom portion of the provider nomination form and attach a completed W-9 Form and a copy of the current malpractice certificate
• Fax or mail the completed forms to:

1st Medical Network
Attn: CCO Nomination Department
1899 Powers Ferry Road, Suite 400
Atlanta, GA 30339
Fax: (877) 376-9260

IMPORTANT NOTE: A separate form must be completed for each provider nominated
A separate form must be completed for each family member who would like to nominate a provider, even if the provider requested is the same as other members of the family making a request

For Example: you wish to nominate Dr. Jones for you, your spouse, and one child, you would need to have three (3) sets of nomination forms completed and returned.

If your nominated provider has questions regarding the nomination form or process, please call (800) 675-6492.

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