AWC Provider Nomination Form

To nominate a provider for consideration into the Anthem Workers' Compensation Network, please fill in the fields below and click on submit. Please note this nomination does not guarantee the nominated provider will become a participating provider of Anthem Workers' Compensation Network. The contracting and credentialing process can take up to 120 days.

* Denotes a required field
Nominated Provider Information
*(Select Applicable State)
California Colorado Indiana Missouri Nevada
* Provider Name: (Last Name and Suffix, First Name, Middle Initial, and Provider Degree - MD, DO, PhD, etc.)

* Group Name: (enter N/A if not applicable)

List DBAs: (enter N/A if not applicable)
License Number:
* Specialty:

Provider TIN:
* Primary Office Address
* Address:
* City:
  * State:
  * Zip:
* Phone:
- - x
- -
Contact Information
* Name: (Last name, First name)
* I am a(n):
Provider   Payor   Injured Worker   Other:  
* Phone:
- - x
- -
* Email Address:
Security Code
* Enter the code displayed in the image below:

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