Practice Info:
PRACTICE NAME*
PRACTICE STATE*
--- ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
NAME OF EMPLOYEE MANAGING DENTAL INSURANCE*
EMAIL OF EMPLOYEE MANAGING DENTAL INSURANCE*
COOPERATIVE ACCOUNT# (Optional. Found on your Summary of Benefits.)
Provider Info:
A Change Form request must be submitted individually for each Provider.
FIRST NAME*
MIDDLE NAME
LAST NAME*
SPECIALTY*
--- General Dentist Dental Anesthetist Endodontist Oral Maxillofacial Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist
PROVIDER EMAIL*
DOES THE PROVIDER HAVE A CAQH PROVIDER ID?*
--- YES NO
CAQH PROVIDER ID
PROVIDER DENTAL LICENSE#*
DENTAL LICENSE STATE*
--- ALABAMA ALASKA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE FLORIDA GEORGIA HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
PROVIDER NPI#*
Carriers Requested:
You may select multiple Carriers. The Practice State in the Practice Info section must be selected to view the corresponding Carriers.
PLEASE SELECT ALL THE PARTNER CARRIERS YOU WOULD LIKE TO SUBMIT YOUR UPGRADE REQUEST TO:*
Careington Cigna Connection DenteMax Guardian Principal Sun Life Zelis Level Humana
Careington Cigna Connection DenteMax Guardian Principal Sun Life Zelis Level Humana
Careington Cigna Connection DenteMax Guardian Principal Sun Life Zelis Level Humana
Careington Cigna Connection DenteMax Guardian Principal Sun Life Zelis Level Humana
Careington Cigna Connection DenteMax Principal Level Humana
Careington Cigna Guardian Principal Sun Life Zelis Level Humana
Change Requests:
A Change Form Request must be submitted individually for each Provider, but you may select multiple change requests.
CHANGE REQUESTS:*
TIN change. Provider Name change. Provider Specialty change. Billing address change. Address change.
Provider Specialty Change:
NEW PROVIDER SPECIALTY*
--- General Dentist Dental Anesthetist Endodontist Oral Maxillofacial Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist
Billing Address Change:
Use to update the billing address with the selected Carriers.
NEW BILLING ADDRESS*
Address Change:
Use to update an existing address. To add a new additional location, click here to use the Add Location Request form.
NUMBER OF LOCATIONS NEEDING ADDRESS CHANGES*
--- 1 2 3 4 5 6 7 8 9 10 +10
NEW ADDRESS* (enter all address changes here)
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.
• Participating Practice must have signed and submitted an Associate Agreement prior to IFM requests.
• Provider, must be included in the original Associate Agreement with the Practice. If not included, Provider must sign and submit an Add Member Provider form 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.
I agree to the Terms and Condition of Participation in this Agreement.
Name of Authorized Agent (required)
Date Agreement Signed mm/dd/yyyy (required)
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. 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 YOUR AREA DIRECTOR.