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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

Change Form Request

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.

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:

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.

CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelis
CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelis
CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelis
CareingtonCignaConnectionDenteMaxGuardianPrincipalSun LifeZelis
CareingtonCignaConnectionDenteMax
CareingtonCignaGuardianSun LifeZelis



Change Requests:

A Change Form Request must be submitted individually for each Provider, but you may select multiple 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.











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.


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 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.







Tax Identification Number (TIN) Info:

Please provide the TIN data for this Provider.








Provider Name Change:

Please provide the new name for the Provider listed above.







Provider Specialty Change:






Billing Address Change:

Use to update the billing address with the selected carriers.





Address Change:

Use to update an existing address. To add a new additional location, click here to use the Add Location Request form.



>>CLICK TO DOWNLOAD W9


>>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.





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: