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Nominations

Your medical plan allows you freedom of choice when selecting a health care provider.

  • Your plan does not utilize a network for physicians or providers
  • As long as your provider submits your claims to the address or payor ID located on the back of your medical ID card, you are only responsible for your applicable copay, deductible and out-of-pocket cost.

As part of ClaimDOC's Pave the Way™ program, a ClaimDOC Member Advocate will reach out to your preferred providers and introduce your new plan. We strongly encourage you to submit this form if you or a family member has an upcoming appointment so we can ensure your provider has the proper information to participate with your plan.

Member First Name:

Member Middle Name:

Member Last Name:

Member Birthday:

Member Last Four of SSN:

Member Email:

Member Phone:

Patient Name:

Relationship: SelfSpouseChild

Gender of Physician Preference: MaleFemaleNone

Patient Birthday:

Patient Last Four of SSN:

Patient Phone:

Urgent: YesNo

Provider Facility Name:

Individual Provider Name:

Client:

Provider Address:

Provider City:

Provider State:

Provider Zip:

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