Forms

The following forms are available for your use. The Group Information Form may be downloaded and submitted by fax to First Choice Health PPO Network (FCH PPO). The Provider Nomination Form can be completed online. Please note that you must hold a contract with FCH PPO in order to complete and/or submit either form.

Group Information Form

If you need to report a group addition, change or termination from our network, please fill out the Group Information Form (also known as Exhibit E to the Contract Holder Agreement).

If you have any questions about how to complete the form, please email ppomarketing@fchn.com, or call and speak with your assigned Account Manager at (800) 231-6935.

Provider Nomination Form

You, or your Participant, may use the Provider Nomination Form to nominate a provider to become contracted with FCH PPO. We welcome all applications. Any application received is subject to strict review to ensure compliance with network membership criteria and credentialing verification. In no way does a completed form guarantee a provider will become preferred with FCH PPO, however we guarantee outreach to that provider will be made.

If you have any questions about the completion of this form, please contact ppopayor@fchn.com, or call (800) 231-6935, Ext. 2105.