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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.

All fields are required unless marked as optional.

Provider Information

Provider Tax ID #

Provider First Name (optional)

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 (optional)

Fax (optional)

Specialty

If a physician, hospital affiliation

Member Information

Member ID#

Member First Name (optional)

Member Middle Initial (optional)

Member Last Name

Member Address

City

State

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

Daytime Phone Number (optional)

Fax (optional)

Email (optional) 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 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.