--- 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
COOPERATIVE ACCOUNT# (optional. On monthly mailed invoice.)
NAME OF EMPLOYEE MANAGING DENTAL INSURANCE*
EMAIL OF EMPLOYEE MANAGING DENTAL INSURANCE*
--- General Dentist Dental Anesthetist Endodontist Oral Maxillofacial Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist
DATE BEGAN PRACTICING DENTISTRY* mm/dd/yyyy
DATE BEGAN AT CURRENT PRACTICE* mm/dd/yyyy
CAQH# (If provider uses CAQH.)
CAQH#* (Required in New Mexico.)
Provider Licenses & Insurance:
STATE DENTAL LICENSE* (file types:gif|png|jpg|jpeg|pdf)
DEA CERTIFICATE* (file types:gif|png|jpg|jpeg|pdf)
MALPRACTICE INSURANCE DECLARATION PAGE* (file types:gif|png|jpg|jpeg|pdf)
TOTAL NUMBER OF LOCATIONS PROVIDER PRACTICES*
--- 1 2 3 4 5 6 7 8 9 10 +10
PROVIDER W9 FOR EACH LOCATION* (1-10 Locations) (file types:gif|png|jpg|jpeg|pdf)
>>CLICK TO DOWNLOAD W9
CV/RESUME/WORK HISTORY* (file types:gif|png|jpg|jpeg|pdf)
CONTROLLED SUBSTANCE/PHARMACY LICENSE (file types:gif|png|jpg|jpeg|pdf)
SPECIALIST CERTIFICATE (file types:gif|png|jpg|jpeg|pdf)
Include any additional miscellaneous documents: (file types:gif|png|jpg|jpeg|pdf)
Include any necessary notes, comments, or instructions:
Terms and Conditions of Participation:
INSURANCE FEE MAXIMIZATION PROVIDER AGREEMENT* (Must be signed by Provider. file types:gif|png|jpg|jpeg|pdf)
>>CLICK TO DOWNLOAD PROVIDER AGREEMENT
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 (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, 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 4 BUSINESS DAYS, PLEASE CONTACT US!