A Humana member brushing her teeth for a healthy smile.

Provider Nomination Form

We don't want you to have to choose between continuing to see your dentist and receiving the best possible value from your dental benefit plan. You can help us get your dentist on our participation list.

* Required fields

Dentist information

Network

PPO DHMO

* Dentist Name Dental specialty Dental Address * City * State ZIP

Your information

* E-mail Address * Patient Name * Phone - - Employer Name Employer's City State My name can be used when contacting my dentist:

Yes No

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