Provider Nomination Form

Provider Nomination Form

If you would like your current provider to receive information about becoming a Preferred Provider, just complete the form below.

The provider named will then receive application information for review. Your submission of this referral form is not a guarantee that the provider named will become a Preferred Provider as not all wish to become a Preferred Provider and not all meet qualifying criteria.

Please Check One	I am a Provider I am an Employer/Payor I am a Member/Patient
If you are an Employer/Payor or Member/Patient, please complete the following
Employer Group Name
Your Name
Your Phone Number
Provider Information
Name
Specialty
Address
Address 2
City, State, ZIP
Phone Number
Fax Number
Contact If Known

Accountable Health Plan of Ohio (AHPO)
C/O The Emerald Health Network
1301 E. 9th Street
Tower at Erieview, 24th Floor
Cleveland, OH 44114

PHONE (216) 902-7529 · TOLL-FREE (866) 744-5152 · FAX (216) 479-2039

E-MAIL AHPOInfo@interplanhealth.com