First Commonwealth DHMO
Dentist Nomination Form
I would like to nominate my current dentist for inclusion in the First Commonwealth DHMO provider network.  I understand that First Commonwealth retains final authority for approving membership in the provider network.   I also understand that First Commonwealth may use my name when contacting my dentist and inform him/her of my desire for them to join the First Commonwealth DHMO network.

NOTE: This form does not serve as an enrollment form for dental insurance or to register with the dental office as a patient.

I have read and accept the above conditions. 

Patient Information

Patient's Name
HMO or PPO
Employer
Telephone
Patient's Email

Dentist Information

Name
Address
Telephone Number
Specialty