If you do not find your healthcare service provider listed in the Physicians Health Plan (PHP) provider directory, please call PHP’s Customer Service department at 1-800-982-6257 to verify their participation status prior to completing this form.

To nominate a non-participating healthcare provider to be considered as a participating provider in our network, please complete the Provider Nomination Form and submit the completed form by fax or mail.

To ensure that all parties understand and agree to participation guidelines, the review and provider credentialing process may take 90 to 120 days from the time all necessary information is received from the provider. Completion of this nomination form does not guarantee inclusion in the network.

Please fax this form to Physicians Health Plan at (260) 432-0493 or mail to Attn: Customer Service, 8101 West Jefferson Blvd., Fort Wayne, IN 46804.