Provider Nomination Form - Injury Management Organization

Provider Nomination Form

Provider Nomination FormMedIngenuity2020-04-28T20:05:44+00:00

* A provider nomination for the IMO Med-Select Network® does not guarantee automatic approval. Additions are based on specialty and demographic needs. All physicians and ancillary providers must meet network credentialing/contracting requirements and accept workers’ compensation. *

Provider Name*
First Last
Provider Specialty*
Provider Phone*
Provider Fax*
Provider Mailing Address*
Street Address Address Line 2 City State Zip Code
Provider Email*
Nominator Name*
First Last
Nominator Email
Nominator Phone*