PPHN Provider Nomination Form

Pennsylvania's Preferred Health Networks (PPHN) offers a comprehensive network of physicians and services that you may choose from for your health care needs. If any of the healthcare professionals accessed by you or your family are not listed in the PPHN Provider Directory or on the PPHN website, please contact us.

Please note: Our participating providers are committed to providing high quality and affordable medical care to our members. Our providers must meet strict credentialing criteria in order to become part of the PPHN network. While we cannot guarantee their participation, we will review each suggestion and contact those providers who meet the criteria for network membership.

If there is a provider you would like us to contact, please complete the information below. If you would like PPHN to notify you if the provider becomes part of our network, please include your address and phone number below.

If you need additional copies of this form, or if you have any questions, please call PPHN at (888) 898-7746.

Date of Request
Provider's Name
Practice Name
If the provider is a physician (check one) Family Practice Internal Medicine Pediatrician OB/GYN Other:
Provider's Address:
Provider's Phone # :
Your Name:
Your Home Address (optional):
Your Phone # (optional):
Your Email Address (optional):
Your Employer's Company Name (if applicable):