Get Provider Nomination Form - Upmc Health Plan

Filling out the Provider Nomination Form for UPMC Health Plan is a straightforward process. This guide will walk you through each section of the form, ensuring you understand how to complete it online effectively.

Follow the steps to fill out the Provider Nomination Form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the 'Group Name' and 'Date of Request' at the top of the form. This information identifies the requesting group and the date of the submission.
3. In the 'Requester Information' section, provide your name, phone number, address, and city, state, and zip code. This information will remain confidential and is used solely for contacting you regarding your nomination.
4. Move to the 'Provider Information' section. Here, fill out the details for the first provider you are nominating, including their name, telephone number, specialty, group name, and group address.
5. Repeat step 4 for additional providers, ensuring accurate information is noted for each provider nomination.
6. Once all required fields are filled, review the form for completeness and accuracy.
7. Finally, save your changes, and consider options to download or print the form for your records. You can then fax the completed form to 412-454-5664 as instructed.

Complete your Provider Nomination Form online today to nominate your chosen providers.