If you are a member, and your provider is not currently participating in our network, you may nominate him/her by completing the following member and provider information. *Indicates a required field.

MEMBER INFORMATION Name: Street Address: City: State: Zip Code: Phone Number: Email Address: Employer: Insurance Carrier/Payor:

If you are a provider interested in the TTC Student Accident network, please complete the following information. *Indicates a required field.

PROVIDER INFORMATION *Provider Name: Specialty: Group Name: Street Address: City: State: Zip Code: Phone Number: Fax Number: Office Manager: Tax ID: Board Status: Institution of Residency: Year Completed: Malpractice Limits: Hospital Privileges (List hospitals where provider has unlimited admitting privileges only):

Thank you for providing the above information. The TTC credentialing process generally takes between 90 - 120 days. This process is dependent upon timely responses, and a prompt return of a completed application and contract documents. TTC will make every effort to add nominated provider's to the network, however, please understand that nominating a provider does not guarantee that they will become a TTC participating provider.