Contact Coventry

• Home
• Contact Coventry
• Provider Network Nomination

Provider Nomination

Thank you for your interest in Coventry's Workers' Comp Networks.  If you would like to nominate a provider to become part of our networks, or if you are a provider and would like to apply to become part of our networks, please fill out the fields in the form below.

First Health

FOCUS

Exclusive Provider Network

MetraComp

First Health Nomination Request

* Required Fields

• Client/Requestor Name(if applicable)
• *Physician First Name
• *Physician Last Name
• *Phone number
• Email Address
• *Address Line 1
• Address Line 2
• *City
• County
• *State Select Your State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• *Zip Code
• *Office Contact
• Degree of Provider
• *Specialty
• Is the provider a member of a group practice? Yes No
• Group Name (required if the provider is a member of a group)
• *Tax ID
• *Hospital Affiliation(s)
• Additional Practice Locations
• Submit

FOCUS Nomination Request

* Required Fields

• Client/Requestor Name(if applicable)
• *Physician First Name
• *Physician Last Name
• *Phone number
• Email Address
• *Address Line 1
• Address Line 2
• *City
• County
• *State Select Your State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• *Zip Code
• *Office Contact
• Degree of Provider
• *Specialty
• Is the provider a member of a group practice? Yes No
• Group Name(required if the provider is a member of a group)
• *Tax ID
• *Hospital Affiliation(s)
• Additional Practice Locations
• Submit

Exclusive Provider Network Nomination Request

* Required Fields

• Client/Requestor Name(if applicable)
• *Physician First Name
• *Physician Last Name
• *Phone number
• Email Address
• *Address Line 1
• Address Line 2
• *City
• County
• *State Select Your State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• *Zip Code
• *Office Contact
• Degree of Provider
• *Specialty
• Is the provider a member of a group practice? Yes No
• Group Name(required if the provider is a member of a group)
• *Tax ID
• *Hospital Affiliation(s)
• Additional Practice Locations
• Submit

MetraComp

Thank you for your interest in MetraComp, Inc.  MetraComp is the largest New York State certified PPO created specifically with workers' compensation in mind.  If you would like to nominate a provider to become part of the MetraComp network, or if you are a provider and would like to apply to become part of the MetraComp network, please Click Here. >>