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Dental Provider Nomination

GEHA Connection Dental Federal members, providers or office personnel may use this form to nominate a dentist to the GEHA Connection Dental® Network. An application packet will be sent to eligible providers.

You can use the "Fill out online" link below to securely send the information electronically to GEHA, or you can click the "Download" link to open a PDF version of the form to print, complete, and return to GEHA by fax or by mail.

If you have any questions, please contact GEHA's Provider CONNECTION at (800) 296-0776. Please complete all the blanks on this form. This information helps us process your request. The nomination process may take three to six months. Not all providers who are nominated will become participating providers in the GEHA provider network.