Enroll Your Provider / Facility

This form is for Verdegard members to request and nominate a health care provider or facility to join the Provider Network of America’s PPO network.

Please complete the form below to the best of your knowledge and a contracting specialist will begin contracting outreach right away.

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Referring Member Information

Check box if you are a MedImpact Employee *

• I am a MedImpact Employee

Member First Name *

Member Last Name *

Member Employer Name *

Member Email Address *

Member Phone *

Member Birthdate *

Provider Facility Information

Provider First Name *

Provider Last Name *

Provider Affiliated Hospital/Clinic

Provider Address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Provider Phone

Provider Office Contact Person

Submit