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This form is for members seeking to nominate a dentist to join the UHC network


Estimated time to complete:

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5 minutes

What you'll need?

To complete this form, you’ll need all, or some of the following:

  • Member last name and first name 
  • Member email address
  • Plan name
  • Plan type
  • Dentist information
  • Dentist specialty
  • Practice name
  • Practice address

We want to process your form as quickly as possible, but missing information will cause delays in processing. 

* Prior to completing this form, please contact Customer Service at the number on your Member ID card to verify that the dentist you want to nominate is not participating with your dental plan.

Instructions: 

If you would like to nominate a non-participating dentist* and/or dental office to join our network, please complete all fields below.

A Network Contractor will contact the dental office to see if they would like to join our network of participating providers. This may take up to 4-6 weeks for recruitment efforts to be completed. Please contact the dental office regarding status of your nomination. 

* Prior to completing this form, please contact Customer Service at the number on your Member ID card to verify that the dentist you want to nominate is not participating with your dental plan. 

Dentist Information

Enter dentist last name

Enter dentist first name

Select the provider specialty

Enter a valid phone number in ###-###-#### format.

Enter the street address

Enter the city

Enter the 2 letter state abbreviation.

Enter the 5 digit ZIP code

Enter the county the dentist’s office is located in. If you don’t know the county name, you can search for it using the dentist office’s address or ZIP code.

Member Information

Enter last name.

Enter first name.

Enter the middle name.

Requires valid email domain (@yahoo.com, @gmail.com, etc.)

Enter a valid phone number in ###-###-#### format.

Select the plan type.

Please review before submitting

Attachments


Maximum 25MB per attachment