Medical provider form

Thank you for your interest in joining Sedgwick's provider networks.

To join a vendor partners’ PPO network in states other than California, click here and complete the Provider Nomination Form.

If you are interested in joining our California medical provider network, please complete the form below. At present, our networks are full but we will accept your application in case an opening becomes available.

Please note that nomination does not guarantee inclusion, but a network liaison should contact you within 30 days of your submission.

First Name*	Last Name*


Email Address*

Phone number*

Company name*

Street address*

City*

State: CA

Zip code*

Briefly describe the services your company can provide:*