Provider Requests

Members may seek the participation of their provider in one of two ways:

• Tell their provider or facility administrator that they wish their participation in the First Choice of the Midwest, Inc. PPO network and have the business office fill out the following form.

• Ask First Choice of the Midwest, Inc. to recruit their provider for them by calling (888) 246-9949, (605) 332-5955 and ask for Provider Relations, or by filling out the provider request form below.

MEMBER REQUEST FOR PROVIDER'S PARTICIPATION: All fields except Address and Member Comments are required Member making Request: Group/Payer: Phone #: Email: Address: City: State: Colorado Idaho Iowa Minnesota Montana Nebraska North Dakota South Dakota Wyoming Zip Code: Provider Name: Clinic or Facility Address: Clinic or Facility City: Clinic or Facility State: Colorado Idaho Iowa Minnesota Montana Nebraska North Dakota South Dakota Wyoming Utah Clinic or Facility Zip: Clinic or Facility Phone: Member Comments:

Email: info@1choicem.com

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