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Dental Provider Nomination Form

GEHA members, providers or office personnel may use this form to nominate a dentist to the GEHA Connection Dental Network™.

GEHA members, providers or office personnel may use this form to nominate a dentist to the GEHA Connection Dental Network. If the dentist of your choice is not listed in the online directory, you may complete this form to nominate the dentist to participate in the Connection Dental network. An application packet and information about Connection Dental will be sent to eligible providers. If your dentist chooses to join the network, the normal time frame to complete the nomination process is about 60 days.

All fields are required unless marked as optional.

Provider Information

Provider Tax ID # (optional) (if known)

Provider First Name

Provider Middle Initial (optional)

Provider Last Name

Facility Name

Physical Address

City

State

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

Daytime Phone Number

Fax (optional)

Specialty (optional)

Member Information

Member ID#

Member First Name (optional)

Member Middle Initial (optional)

Member Last Name

Member Address

Member City

Member State

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

Member Daytime Phone Number (optional)

Member Fax (optional)

Email Address 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.

Comments (optional)

If you have any questions, please contact GEHA's PPO CONNECTION at (800) 296-0776. Please complete all the blanks on this form. This information helps us process your request. Not all providers who are nominated will become participating providers in the Connection Dental Network.