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FORMS - Provider Nomination Form
 

OneNet PPO welcomes the opportunity to work with payer, participants and health care professionals in identifying physicians and other health care practitioners to include in our networks.

Participants & Payers:
Please complete and submit the form below if you would like to nominate a non-participating physician or health professional for inclusion in the OneNet PPO, MAPSI Behavioral Health, OneNet Workers Compensation or OneNet Dental networks. OneNet will review your request and, if appropriate, contact the nominated provider to discuss his or her interest in joining our network.
Nominations are not a guarantee of future participation. A provider's participation will depend on multiple considerations, including current physician availability, satisfying OneNet's provider credentialing requirements, and the provider's interest in joining a PPO network. Please be aware that, if selected, it can take several months to perform the credentialing procedures required for participation in our networks.
If you have any questions regarding the nomination process, please call OneNet Member Services at 1-800-342-3289. 		Physicians & Health Care Practitioners:
If you are not currently part of the OneNet network, and are interested in joining, please complete and submit the form below. You will be contacted by our network representatives to discuss your participation in our network and satisfactory completion of our credentialing and selection criteria. Our selection criteria include, but are not limited to, the following:
  • Established need by region or specialty

  • State license (unrestricted)

  • Work history

  • Verification of Credentials

  • 24-hour office coverage

  • Office survey

  • Professional liability insurance ($1 million to $3 million required)
OneNet is a wholly owned subsidiary of United Healthcare Insurance Company, a part of UnitedHealth Group, Incorporated.
For more information on joining, please call OneNet Professional Services at 1-800-342-6141.

Print a PDF copy of our Provider Nomination Form

Provider Nomination Form
Name of person submitting this nomination:
Telephone number(xxx-xxx-xxxx):
E-mail:
I am a: (select one)
OneNet Participant Provide Group Name:
OneNet Payer/TPA Provide Payer/TPA Name:
Provider/Provider Representative Provide Practice Name:
Nominee:
Physician / Health Care Professional Name:
Provider Practice Name:
Specialty:
Main Office Address:
City:
State:
ZIP:
Provider Telephone (xxx-xxx-xxxx):