Get Dentist Nomination Form - Ncretiree

The Dentist Nomination Form - NCRetiree is an important document for nominating a dentist to be part of your health plan. This guide will provide you with step-by-step instructions on how to seamlessly fill out this form online.

Follow the steps to complete the Dentist Nomination Form online.

1. Click the ‘Get Form’ button to access the Dentist Nomination Form - NCRetiree and open it in your preferred online editor.
2. Begin by filling in the dentist's name in the designated field. Ensure that you write the name clearly to avoid any confusion.
3. Next, enter the practice name where the dentist operates. This helps in identifying the practice associated with the nomination.
4. In the following field, provide the complete address of the dental practice, including street address, city, state, and zip code.
5. Fill in the county of the dental practice. This information may be helpful for network assessment.
6. Enter the dentist’s phone number so that the network recruitment team can contact them if necessary.
7. In the next section, provide the member's name who is submitting the nomination. This identifies the requestor.
8. Next, fill in the member's phone number for any follow-up communications regarding the nomination.
9. Select the type of plan you are enrolled in by checking the appropriate box: Dental HMO, Dental PPO, or Government Programs.
10. If you are nominating a California provider, fax the completed form to 714-513-6490, or send it via e-mail to kimberly_p_sheldrake@optumhealth.com. For all other provider nominations, fax the form to 877-572-3043 or email it to networkrecruit@uhc.com.
11. After reviewing all the information you entered, make sure everything is accurate and complete. You can then save your changes, download a copy, print the form for physical submission, or share it as needed.

Complete your Dentist Nomination Form online today and ensure your preferred dentist is recognized!