Provider Nomination

Workers' Compensation
Provider Nomination Form

As we strive to maintain a strong network that will meet your business needs, please help us identify all medical providers and facilities you would like to see become a part of The First Health Network.

To proceed, we must have the name of the provider, address, phone number, and tax identification number.

If you have any questions regarding this process, please call Amy Scholtes at 864-240-5843 or e-mail ascholtes@hewittcoleman.com.

Provider/ Practice Name

Provider Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Tax ID #

Nominator Name

Nominator Company

Nominator E-mail