Signature Networks Plus - Physician Nomination Request
City of Burbank P r o v i d e r N o m i n a t i o n F o r m
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Our new automated Nomination procedure requirst that you download and complete the Acknowledgement Form prior to starting the process. Also, if you plan on uploading a list of providers, please download our template and complete that too. The nomination procedure is subject to time-out for security pruposes, so have your documenation completed before starting the process.
| Download and Prepare the Acknowledgement Form (Required) | |
|---|---|
| Download the Physician Acknowledgement Form here | City of Burbank Physician Acknowledgement |
| Download and Prepart the Provider List (Optional) | |
| Click here to download template | nomination-request-list.xlsx |
Prepare Document(s) in Advance and Proceed
Please allow 6-8 weeks for your nomination to be processed and for contractual material to be issued.