PROVIDER NOMINATION FORM – Cigna HEALTHCARE NETWORK

Return this form to your Human Resources Department
Note: It can take 3 – 6 months from the date Cigna contacts the physician before a decision is reached.

Employee Name: ______

Employer Name: Carlisle Corporation

I would like the following doctor to be contacted for participation in the Cigna Open Access Plus Network:

Physician Name

Office Manager’s Name

______

Phone Number

Address

City State Zip Code

Primary Specialty Primary Admitting Hospital

I have contacted my physician regarding joining the Cigna Open Access Plus Network: ______YES ______NO

I understand the existing network in my area may not be accepting new physicians at this time. Also, I understand there is no guarantee that the doctor I have nominated to participate in the network will meet the credentialing requirements. Even if my doctor qualifies, he or she may choose not to participate.

Employee’s Signature Date

To be completed by Human Resources
Return completed form to Ann Thomas at Cigna: Fax No. 860.731.3630
Account Number / Account Name / Please check
3335183 / Carlisle Corporate
2498942 / Carlisle Brake & Friction
2498943 / Carlisle Food Service Products
2498944 / Carlisle Transportation Products
2498945 / Carlisle Interconnect Technologies
2499086 / Carlisle Construction Materials

______

Human Resource Signature Date