Provider Nomination Form

Provider Nomination Form

To receive the highest level of benefits your group plan allows, you must receive your healthcare from a First Choice Health PPO Network (FCH PPO) preferred provider. If your provider is not contracted with FCH PPO, you may want to ask whether s/he is interested in applying for membership. We would be happy to process your request if you would please complete the form below with the requested information. Once the completed form is received, we will review and follow up directly with your provider.

Please note that completion and submission of this form does not guarantee the provider nominated will join our network, nor does it commit FCH PPO to contract with the provider. By submitting this form, you are giving permission to FCH PPO to use your name and your employer’s name (if applicable) in contacting the nominated provider regarding FCH PPO network participation.

First Choice Health PPO Network (FCH PPO) appreciates your nomination of healthcare providers for membership. All applications are processed to ensure compliance with network membership criteria and credentialing verification. This credentialing process may take several weeks (average is six to eight weeks) and membership is subject to approval. We appreciate your patience.

Please be aware of our Network Closure for select specialties in Washington State.

Provider Information

6/17/2024