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 PPO network and have the business office fill out the following form.

• Ask First Choice of the Midwest 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: South Dakota Montana Wyoming North Dakota Nebraska Minnesota Iowa Colorado Utah Zip Code: Provider Name: Clinic or Facility Address: Clinic or Facility City: Clinic or Facility State: South Dakota Montana Wyoming North Dakota Nebraska Minnesota Iowa Colorado Utah Clinic or Facility Zip: Clinic or Facility Phone: Member Comments:

Email: info@1choicem.com

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