Provider Nomination Form Logo

  • Provider Nomination Form

    Please nominate your providers and we will contact them about joining our Preferred Provider list.

  • Introduction:

    Our Members have the opportunity to nominate any Providers they think would be a good fit to establish a Direct Agreement with Solidarity. A Direct Agreement can ensure a smooth billing process, payment methods, and established billing rates.

    In order to nominate your Providers, please fill out the information below so that our Provider Relations Team can contact them about obtaining a Direct Agreement. Our team will contact you if a Direct Agreement is obtained with a Provider you nominated. If you are nominating more than five (5) Providers, please fill out an additional Provider Nomination Form.

    To learn more about the Provider Nomination Form, please visit our Knowledge Center.

    If you have any questions, please contact our team at support@solidarityhealthshare.org or call us at (844) 313-4999 option 2.

  • Please note: If this request is being submitted related to an upcoming surgery, current cancer treatment or maternity services, this request needs to go through our Care Coordination team. Please call 844-313-4999 option 2 to get in touch with us.


  • Provider Information

  • Provider 1

  • Provider 2

  • Provider 3

  • Provider 4

  • Provider 5

  • Review Your Provider Nomination

  • Please review the information you entered before submitting your form

     

    Membership ID Number: {MembershipId}

     

    Member Name: {MemberName}

     

    Member Email: {MemberEmail}

     

    Number of Providers Nominated: {NumberOfProviders}

     

    Provider 1: {FacName1}

  • Provider 2: {FacName2}

  • Provider 3: {FacName3}

  • Provider 4: {FacName4}

  • Provider 5: {FacName5}

  • Should be Empty: