Provider Nomination

Please fill out the form below to nominate a provider, and our Provider Relations team will reach out to the provider. In the meantime, we find that it is most effective if you contact the provider directly and request that he or she apply for participation on your plan. Completing this request does not guarantee that the provider will become contracted. The provider must complete the credentialing process and meet EMI Health’s requirements for participation.

Please correct the following errors:

Submitter's Information

Zip format: XXXXX or XXXXX-XXXX
Phone Number format: XXX-XXX-XXXX

Provider's Information

Phone Number format: XXX-XXX-XXXX