Group Dental Insurance | Mutual of Omaha

Nominate a Provider

If the provider of your choice does not participate in the Mutually Preferred® network or the VIP Dental Network℠, submit their information using the form below and we'll extend an offer to them to join our network.

To nominate a provider, please choose your network and fill out the form.

Mutually Preferred® Network

VIP Dental Network℠

Recommend Your Dentist Form for Mutually Preferred® Network

All fields are required unless indicated as optional

Dentist Information

Provider Office Name (Optional)

Provider First Name Please provide a Provider First Name

Provider Last Name Please provide a Provider Last Name

Provider Address Please provide a Provider Address

City Please provide a City

State

Please select a State

ZIP Code Please provide a ZIP Code

Specialty (check all that apply)

General Dentistry

Oral/Maxillofacial Surgery

Pediatric Dentistry

Endodontics

Periodontics

Prosthodontics

Orthodontics

TMJ

Please select an option

Other Specialty (Optional)

Dentist Contact Information

Provider Email Address (Optional) Please provide a Provider Email Address

Provider Phone Number Format: 555-123-4444 Please provide a Provider Phone Number

Provider Fax Number (Optional) Format: 555-123-4444

Provider Contact Name (Optional) Please provide a Provider Primary Contact

Provider Contact Email Address (Optional) Please provide a Primary Contact Email Address

Your Information

Your Employer (Optional)

Please note: the network contracting process for joining the Mutually Preferred® Dental Network can take up to 120 days to complete, and incomplete forms will not be reviewed.

Recommend Your Dentist Form for VIP Dental Network℠

My Information

All fields are optional in this section

First Name Please provide your First Name

Last Name Please provide your Last Name

Email Please provide your Email

ZIP Code Please provide your ZIP Code

Employer Please provide your Employer

VIP Dental Network℠ Please provide your VIP Dental Network℠

My Dentist Information

All fields are required in this section

First Name Please provide your Dentist's First Name

Last Name Please provide your Dentist's Last Name

Address Please provide your Dentist's Address

City Please provide your Dentist's City

State

Please select your Dentist's State

ZIP Code Please provide your Dentist's ZIP Code

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