Get Multiplan Nomination

Filling out the Multiplan Nomination form is an essential step in nominating your preferred healthcare practitioner for participation in The MultiPlan Network®. This guide provides clear and concise instructions to help you navigate the process with ease.

Follow the steps to complete your nomination form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your name at the top of the form. This identifies you as the individual making the nomination.
3. In the 'About You' section, provide the name of your health plan administrator. This information helps in processing your nomination effectively.
4. Next, proceed to the 'About the Practitioner to be nominated' section. Here, you must enter as much information about the physician as possible. Note that required fields are marked with an asterisk (*).
5. Enter the practitioner's name, including their last name, first initial, and first name in the designated fields. Ensure the accuracy of spelling as this information is crucial.
6. Complete the practice location section by providing the street address, city, state, and zip code. This information helps in accurately identifying the practitioner's location.
7. Include the practitioner's telephone number and fax number if available, as this assists in further communication.
8. In the 'Other Identifying Information' section, specify the practitioner's specialty (e.g., pediatrics, cardiology) and their degree (e.g., MD, DO). Provide their Tax ID number if you have it.
9. If applicable, mention the medical group to which the practitioner belongs and list any hospital affiliations where the physician has admitting privileges.
10. Once you have filled out all relevant sections, review the information for accuracy and completeness before submitting your nomination.
11. Finally, save your changes, download, print, or share the completed form as needed. Ensure it is mailed or faxed to MultiPlan Practitioner Recruitment at the provided address.

Complete your Multiplan Nomination form online today to nominate your preferred healthcare practitioner.