 First Choice Health Home : PPO Network : For Payors : Forms
Forms
The following forms are available for your use. The Group Information Form may be downloaded and submitted
by fax to FCHN. The Provider Nomination Form can be completed online. Please note that you must hold a
contract with FCHN in order to complete and/or submit either form.
- Group Information Form
- Provider Nomination 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 FCHN. 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 FCHN, 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.
|