NOMINATE A PROVIDER Nominate a Provider Nominee's Name * Hospital, Facility, or Practice Office Phone Street Address City State Zip Reason for Nomination New Option Couldn't find on lookup screen Claim denial Patient Billing company Submitter's Email Address (if you wish to be contacted about your submission) Only if you wish to be contacted about your submission. Submitter's Name Submitter Type Choose Type I am a provider I am an employer or payor Other Email Submit Top
