Provider Nomination Form

Provider Nomination Form

Please nominate your providers and we will contact them about joining our Preferred Provider list.
America's HealthShare
Introduction:

Our Members have the opportunity to nominate any Providers they think would be a good fit to establish a Direct Agreement with America's HealthShare. A Direct Agreement can ensure a smooth billing process, payment methods, and established billing rates.

In order to nominate your Providers, please fill out the information below so that our Provider Relations Team can contact them about obtaining a Direct Agreement. If you are nominating more than five (5) Providers, please fill out an additional Provider Nomination Form.

To learn more about the Provider Nomination Form, please visit our Resource Center.

If you have any questions, please contact our team at providerrelations@americashealthshare.org.
Is this request related to an upcoming surgery, current cancer treatment or maternity services?
Please note: If this request is being submitted related to an upcoming surgery, current cancer treatment or maternity services, this request needs to go through our Care Coordination team. Please call 844-570-1776 option 2 to get in touch with us.
Membership ID Number
Member First Name
Member Last Name
Primary Member Email Address

Confirmation Email
How many Providers would you like to Nominate?

Provider Information
Provider 1
Facility Name
Facility City/State

Street Address

Street Address Line 2

CityState

Zip Code
Contact Name
Contact Phone
Provider Specialty
Provider Specialty
If the specialty you are looking for isn't in these options above, please select "Other"
If "Other" was selected, please describe Specialty
Are you an established patient with this provider?
Provider 2
Facility Name
Facility City/State

Street Address

Street Address Line 2

CityState

Zip Code
Contact Name
Contact Phone
Provider Specialty
Provider Specialty
If the specialty you are looking for isn't in these options above, please select "Other"
If "Other" was selected, please describe Specialty
Are you an established patient with this provider?
Provider 3
Facility Name
Facility City/State

Street Address

Street Address Line 2

CityState

Zip Code
Contact Name
Contact Phone
Provider Specialty
Provider Specialty
If the specialty you are looking for isn't in these options above, please select "Other"
If "Other" was selected, please describe Specialty
Are you an established patient with this provider?
Provider 4
Facility Name
Facility City/State

Street Address

Street Address Line 2

CityState

Zip Code
Contact Name
Contact Phone
Provider Specialty
Provider Specialty
If the specialty you are looking for isn't in these options above, please select "Other"
If "Other" was selected, please describe Specialty
Are you an established patient with this provider?
Provider 5
Facility Name
Facility City/State

Street Address

Street Address Line 2

CityState

Zip Code
Contact Name
Contact Phone
Provider Specialty
Provider Specialty
If the specialty you are looking for isn't in these options above, please select "Other"
If "Other" was selected, please describe Specialty
Are you an established patient with this provider?

Review Your Provider Nomination
Please review the information you entered before submitting your form

Membership ID Number: {MembershipId}

Member Name: {memberFirst} {memberLast}

Member Email: {MemberEmail}

Number of Providers Nominated: {NumberOfProviders}

Provider 1: {FacName1}
Provider 2: {FacName2}
Provider 3: {FacName3}
Provider 4: {FacName4}
Provider 5: {FacName5}
Other Specialty: {ifother}{ifother2}{ifother3}{ifother4}{ifother5}
Should be Empty:

Provider Nomination Form

Provider Information

Review Your Provider Nomination