Provider Nomination Form - Qualcomm Premier Plans

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Your dedicated concierge team provides phone and email support exclusively to Premier Plan members with clinical support available after hours.

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Nominate your provider

Qualcomm members have the opportunity to identify providers for consideration in the Qualcomm Premier Plan network. If you find that a particular provider of your choice is not part of the network, we have provided the following mechanism to notify us by filling out the simple form below. This notification will serve as nomination of the provider to be considered for inclusion in the Qualcomm Premier Plan network. A Scripps concierge team member will get back to you to let you know if that provider will be added to the network.

Your first name *

Your last name *

Your email *

Your phone number *

Provider first name *

Provider last name *

Provider phone number

Provider address

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