Provider Nomination

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

* First Name

* Last Name

* Employer

* Address

* City

* State

* Zip

Zip format: XXXXX or XXXXX-XXXX

* Phone

Phone Number format: XXX-XXX-XXXX

* Email Address

Provider's Information

* Please choose a provider type

Medical Dental

* Plan

* Provider Specialty

* First Name

* Middle Initial

* Last Name

* Address

* City

* State

* Zip

* Phone Number

Phone Number format: XXX-XXX-XXXX

Email Address

Permission to use your name May we use your name when contacting this provider?