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I would like to nominate my current dentist for inclusion in the First Commonwealth DHMO provider network. I understand that First Commonwealth retains final authority for approving membership in the provider network. I also understand that First Commonwealth may use my name when contacting my dentist and and inform him/her of my desire for them to join the First Commonwealth DHMO network.
NOTE: This form does not serve as an enrollment form for dental insurance or to
register with the dental office as a patient.
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