(800) 853-7003

Provider Nomination Form

Thank you for your interest in joining the IMS network.

PATIENTS/PAYERS: Please use this form to nominate a provider you would like us to contact about joining our network.

PROVIDERS: Please use this form if you would like more information about how your practice/facility can be a part of the IMS network.

After submitting this form, our provider relations department will contact the provider. If you have any questions, please contact us at 1-800-853-7003.

All nominations must include a valid phone number and a valid email address.


MemberPayer/TPAProvider/Provider Representative

Please note that all fields with an * next to it are required fields. If you are a provider, please complete the entire Provider's Information Section.

Your Information

Provider's Information