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Application

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Add a Cooperative PPO partner to your insurance mix. Complete the form below to become directly contracted with a carrier partner. Follow the steps below:

Step 1) For first-time insurance requests through the Cooperative, an Initial Provider Data form must be submitted for each provider prior to the Provider Application request. Click here to complete the Initial Provider Data form.

Step 2) Review the associated fee schedule posted in Member Services. If the fees are acceptable, continue to Step 3.

Step 3) Verify you are NOT already directly contracted with the Carrier. Phone numbers for verifying are provided in the form process.

Step 4) Use the form below to submit a Provider Application Request with the Dental Cooperative insurance partners. Application requests will be processed only if the following criteria are met:

  • Provider is a current paying Member of the Dental Cooperative.
  • Provider is not directly contracted with the Carrier. Instructions to verify a direct contract are provided in the form below after you choose your requested Carriers.
  • For first-time insurance requests through the Cooperative, an Initial Provider Data form must be submitted prior to the Upgrade Request. Click here to complete the Initial Provider Data form.
  • All information requested must be included and current. Missing or expired data will delay the submission process.
  • Applications are submitted on behalf of Cooperative members, but Carriers reserve the right to restrict and deny requests based on their own criteria.

If you are having trouble with the form or need help, please contact your local Area Director for assistance.

    INSURANCE FEE MAXIMIZATION

    Provider Application Request Form

    A Provider Application Request can only be submitted for one Provider per form, but you may select multiple Carriers.
    Request forms should not be submitted if the Provider's Dental License, Malpractice Insurance, or DEA Certificate is within 60 days of expiration, due to expiration during processing. If within 60 days, please submit this request after the new Dental License, Malpractice Insurance, or DEA Certificate has been received.


    Membership Info:

    Requests can only be submitted for current Dental Cooperative Member Providers.

    Requests can only be submitted for current Dental Cooperative members. Please contact your local Area Director to add your Provider to the Dental Cooperative before submitting a request. Click here to find your local Area Director:



    New Providers are required to submit an Initial Provider Data form. Please click here to complete the Initial Provider Data form prior to your request.



    Practice Info:

    *required









    Carriers Requested:

    An Provider Application Request must be submitted individually for each provider. You may select more than one Carrier request per Provider.
    Select a Practice State in the Practice Info section to view the corresponding Carriers.

    CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelis
    CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelis
    CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelis
    CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelis
    CareingtonCignaConnectionDenteMax
    CareingtonCignaGuardianSun LifeZelis



    Participation Info:

    Only Providers NOT directly contracted with the selected Carriers should submit a Provider Application Request form. Use the phone numbers below if you need to verify if a Provider is already directly contracted:



    Careington Provider Relations Team 1-800-441-0380 (option 8)


    Cigna Provider Relations Team 1-800-244-6224


    Connection Provider Relations Team 1-800-821-6136


    DenteMax Provider Relations Team 1-800-752-1547


    Guardian Provider Relations Team 1-800-890-4774


    Principal Provider Relations Team 1-800-638-1959


    Sun Life Provider Relations Team 1-800-434-2638


    Zelis Provider Relations Team 1-800-878-7896



    Provider Info:

    An Provider Application Request form must be submitted individually for each provider.










    Request forms should not be submitted if the Provider's Malpractice Insurance is within 60 days of expiration. Please submit this request after the new Malpractice Insurance has been received.



    >>CLICK TO DOWNLOAD W9


    >>CLICK TO DOWNLOAD W9



    Provider License Data:

    Please provide the most current license information for the Provider listed above.
    Request forms should not be submitted if the Provider's Dental License is within 60 days of expiration. Please submit this request after the new Dental License has been received.







    Provider DEA Certificate Data:

    Please provide the most current DEA (Drug Enforcement Agency) certificate information for the Provider listed above.
    Request forms should not be submitted if the Provider's DEA Certificate is within 60 days of expiration. Please submit this request after the new DEA Certificate has been received.







    Include any additional miscellaneous documents:(file types:gif|png|jpg|jpeg|pdf)




    Include any necessary notes, comments, or instructions:






    To qualify for Insurance Fee Maximization through the Dental Cooperative, Providers must meet the following criteria:
    • Provider must be a current, paying member of the Dental Cooperative in good standing.
    • Provider, if not a current Member and/or not included in the original Associate Agreement with the Practice, must sign and submit an Add Member Provider form prior to IFM requests.
    • Participating Practice must have signed and submitted an Associate Agreement prior to IFM requests.
    • Provider who has terminated their Dental Cooperative membership will have access to fee schedule resources terminated.
    • The Dental Cooperative will inform Carriers of membership termination and Carriers will take appropriate action as their individual policies dictate, which may include but not limited to a downgrade of fee schedule, return to previous fee schedule prior to membership or upgrade, or change to a base fee schedule indicated by the carrier.
    • Provider must sign and return Insurance Fee Maximization provider Agreement prior to any IFM requests.

    • The Dental Cooperative acts within the SEC parameters of a Messenger Model. Carriers reserve the right to restrict and deny requests based on their own criteria.





    Once submitted, we will verify your membership and information. Once verified, you will receive an email with instructions for the next step. Just hold tight until you receive the email.

    Please confirm the form submits, sometimes it takes a minute to go through. You will get a "Success!" message at the bottom of this form if it submits correctly. IMPORTANT: IF YOU DO NOT RECEIVE A CONFIRMATION EMAIL THAT WE RECEIVED YOUR DATA WITHIN 5 BUSINESS DAYS, PLEASE CONTACT US!

    Having issues submitting the online form? Please contact your local Area Director: