Medical Provider Nomination Form

GEHA members, providers or office personnel may use this form to nominate a physician or hospital to the GEHA provider network. Complete the information below and select Submit to send this form electronically to GEHA.

Provider Information
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(if known)

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Please enter the Provider's five-digit ZIP Code.

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Member Information
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Please enter the Member's five-digit ZIP Code.

By providing your email address, you agree to receive email news and information from GEHA. You have the ability to opt out from within any email communication you receive from GEHA.

If you have any questions, please contact GEHA's Customer Service department at (800) 821-6136. Please complete all the blanks on this form. This information helps us process your request. The nomination process may take three to six months. Not all providers who are nominated will become participating providers in the GEHA provider network.