Provider Nomination Form

Your ClearChain medical plan is open-access and network-free. This means that you have the freedom to choose any provider you wish, without restrictions or limitations from your plan.

To ensure your provider will participate in ClearChain Health, complete this Provider Nomination Form below. Our member support team will contact your healthcare provider BEFORE your first appointment to educate them on your new plan and ensure they have the necessary information to submit your claims.

Employee Information
Employer*
First Name*
Last Name*
Employee Date of Birth*

Date Format: MM slash DD slash YYYY MM/DD/YYYY
Member ID Number

This is located on your medical ID card. If you don’t have one yet or you don’t have your ID on you, no worries, go ahead and skip this field.
Which health care provider location should we contact?
Name of Facility/Practice/Clinic*
Facility Contact Telephone Number*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Now we’ll fill out the patient information.
Patient Information*
Patient Name Patient Date of Birth Relationship to Employee New or existing patient? Practitioner First Name Practitioner Last Name Practitioner Type

*Please complete the fields above for each patient on your plan. Use the plus sign on the right to add additional information for each patient. Self, Spouse, Dependent
Please check here if you do have an appointment scheduled
- I do have an appointment scheduled
Appointment Date
MM slash DD slash YYYY

Date Format: MM slash DD slash YYYY MM/DD/YYYY
Who should we update once we get in touch with the provider?

Your contact info will only be used to provide you with updates regarding the providers you nominate. We will not send you spam.
Contact First Name*
Contact Last Name*
Contact Phone*
Contact Email*
Preferred Contact Method*
Can we leave a detailed voicemail?*
Is there anything else we should need to know?

If you prefer to mail or email your Provider Nomination Form, download the form here and submit it to:

ClearChain Health
4230 Tuller Rd, Dublin, OH 43017

Email member support at benefits@clearchainhealth.com

Check the status of your provider nomination at any time by calling.
phone: 833-733-8478
fax: 614-467-3610