Change Form Request

Things change. We get it.

Use the form below to submit a Change Form request with the Dental Cooperative insurance partners. Change form requests include the following:

Change a provider’s TIN (Tax Identification Number)
Change a provider’s name.
Change a provider’s specialty.
Change your billing address.
Change the address of your existing primary location. If you are adding a new location, click here to complete an Add Location Request.

INSURANCE FEE MAXIMIZATION

A Change Form 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.
PROVIDER IS A CURRENT MEMBER OF THE DENTAL COOPERATIVE*

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:

IS THIS A NEW ASSOCIATE TO YOUR PRACTICE?*

FOR THIS NEW ASSOCIATE, HAVE YOU ALREADY SUBMITTED AN "INITIAL PROVIDER DATA" FORM?*

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

PRACTICE NAME*

PRACTICE STATE*

COOPERATIVE ACCOUNT# (optional. Found on your Summary of Benefits.)

NAME OF EMPLOYEE MANAGING DENTAL INSURANCE*

EMAIL OF EMPLOYEE MANAGING DENTAL INSURANCE*

Carriers Requested:

A Change Form Request must be submitted individually for each Provider, but you may select multiple Carriers.
Select a Practice State in the Practice Info section to view the corresponding Carriers.

PLEASE SELECT ALL THE PARTNER CARRIERS YOU WOULD LIKE TO SUBMIT YOUR CHANGE FORM REQUEST TO:*

CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelisLevelHumana

CareingtonCignaConnectionDenteMaxPrincipalLevelHumana

CareingtonCignaGuardianPrincipalSun LifeZelisLevelHumana

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 Info:

A Change Form Request must be submitted individually for each Provider.

FIRST NAME*

MIDDLE NAME

LAST NAME*

SPECIALTY*

PROVIDER EMAIL*

PROVIDER'S NPI#*

CAQH# (If provider uses CAQH.)

CAQH#* (Required in New Mexico.)

Provider Malpractice Insurance:

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

PROVIDER MALPRACTICE INSURANCE DECLARATION PAGE* (file types:gif|png|jpg|jpeg|pdf)
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.

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 DENTAL LICENSE#*

DENTAL LICENSE STATE*

DENTAL LICENSE EXPIRATION DATE* mm/dd/yyyy

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.

PROVIDER DEA CERTIFICATE #*

DEA CERTIFICATE STATE*

DEA CERTIFICATE EXPIRATION DATE* mm/dd/yyyy

Tax Identification Number (TIN) Info:

Please provide the TIN data for this Provider.
LEGAL NAME OF ENTITY*

TAX IDENTIFICATION NUMBER (TIN)*

ENTITY TYPE*

REGISTERED STATE*

NAME OF PRIMARY ENTITY OWNER/OFFICER*

Provider Name Change:

Please provide the new name for the Provider listed above.

FIRST NAME*

MIDDLE NAME

LAST NAME*

Provider Specialty Change:

NEW PROVIDER SPECIALTY*

SPECIALTY CERTIFICATE* (file types:gif|png|jpg|jpeg|pdf)

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*

NEW ADDRESS* (enter all address changes here)

PROVIDER W9 FOR EACH LOCATION* (1-10 Locations)(file types:gif|png|jpg|jpeg|pdf)
>>CLICK TO DOWNLOAD W9

PROVIDER W9 FOR EACH LOCATION* (10-20 Locations)(file types:gif|png|jpg|jpeg|pdf)
>>CLICK TO DOWNLOAD W9

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.

I agree to the Terms and Condition of Participation in this Agreement.

Name of Authorized Agent (required)

Date Agreement Signed mm/dd/yyyy (required)

Signature of Authorized Agent* (Draw/sign below)

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: