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Initial Provider Data

Hey there first-timer!

Providers who are doing any kind of Insurance Fee Maximization for the first time with the Dental Cooperative must complete the form below before we can start any actions on your behalf. All data is required to submit the form and begin any insurance process.

    INSURANCE FEE MAXIMIZATION

    Initial Provider Data

    Prior to submitting any Insurance Fee Maximization request, Providers must submit an Initial Provider Data form once per Provider.

    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









    Provider Info:












    Provider Licenses & Insurance:







    >>CLICK TO DOWNLOAD W9


    >>CLICK TO DOWNLOAD W9






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




    Include any necessary notes, comments, or instructions:




    Terms and Conditions of Participation:


    >>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.





    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!

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