Forms & Brochures > Provider Nomination

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 Form to send this form by email to GEHA.

Provider Information

  Provider Tax ID#    (if known)
  Provider Name
  Facility Name
  Physical Address
  Daytime Phone Number
  If a physician, hospital affiliation  

Member Information

  Member ID#
  Daytime Phone Number
  Email Address

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.

If you have any questions, please contact GEHA's Provider CONNECTION at (800) 296-0776. 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.