Indiana Teamsters Health Benefits Fund - Provider Nomination Form

Indiana Teamsters Health Benefits Fund

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Nominating a Provider

ADVANTAGE has successfully contracted with hospitals, physicians and ancillary providers throughout the State of Indiana. While we believe we have provided you and your family with access to the appropriate numbers and types of providers, we understand that you may have an existing relationship with a doctor not currently participating with either ADVANTAGE or PHCS. If you find that your doctor is not currently participating, please complete the information below and then click on the “Submit” button at the bottom of the form.

Although we cannot guarantee that your doctor will participate, we will certainly review your request and make a determination based on the information you provide us. If we find that other Indiana Teamsters Health Benefits Fund employees have been receiving care from your doctor, we will certainly contact the doctor about participating with ADVANTAGE. If the doctor is interested in participating, we will let you know as soon as possible.

Please fill out the form below and hit the "Submit" button and we will get back to you as soon as possible.

Provider Nomination Form

Doctor’s Name: (first, last)
Doctor’s Address: (street)
(city, state, zip)
Doctor’s Office Phone Number:
Group Practice Name (if applicable):
Your Name: (first, last)
Your Daytime Phone Number:
Your Address: (street)
(city, state, zip)

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