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.

Please enable JavaScript in your browser to complete this form.

Referring Member Information

Check box if you are a MedImpact Employee *

• I am a MedImpact Employee

First Name *

Last Name *

Employer Name *

Email Address *

Phone *

Birthdate *

Provider Facility Information

First Name *

Last Name *

Affiliated Hospital/Clinic

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

Phone

Office Contact Person

Submit