Member nomination form

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Provider Nomination Form

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Please complete this form to nominate an International Provider for direct settlement.

Part A: Member Information

*Your Name

*City

*Country

*Email

*Employer Name

Part B: Provider Information

*Hospital / Clinic Name

*City

*Country

*Address

*Hospital Contact

*Title

*Telephone

*Number of Annual Visits

*Email

*Additional Comments

Are you a provider looking to join our network? Fill out our provider submission form to give us all your details.

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