Provider Preferred Specialist List

Please use this form to list your preferred specialists. If any of your preferred specialists are not currently In-network with the specified Health Plan, we will take the necessary steps to get them contracted.

Your Office Info:

HMO*

Office Name*

Office Contact Name*

Specialist Info:

Please select the number of specialists you would like to add, up to 5

Specialist 1:

Specialist Name*

Specialty*

Specialist Phone Number*

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