Provider Nomination Form

Ameritas Life Insurance Corp. (Ameritas Group) continually recruits new dentists and specialists to join their Participating Provider Organization (PPO). If you are a member who has the PPO benefit and your dentist is not an active participating provider, you may request that an application packet be sent to their office for consideration of our program. Please complete the Provider Nomination in its entirety to ensure the appropriate information is sent to the office.

* = Required

Provider Information

* Provider Name: Specialty: Name of Practice:
* Street Address:
* City: * State: * Zip:
Phone Number: Fax Number:

Your Information

* Member Name:
* Street Address:
* City: * State: * Zip:
Phone Number: E-mail Address:
* Employer:

It is helpful if we are able to share the name of the person who nominated the provider to participate in our network. May we use your name when contacting this provider? Yes      No

Thank you for providing the above information. The provider application and credentialing process generally takes about 2 weeks. Ameritas Group will make every effort to add nominated providers to the network. Please understand that nominating a provider does not guarantee they will become an active participant in the Ameritas PPO network.

AmeritasAcacia Companies
M01

nomprov.htm